CLM-2026-006412
Harbor Medical Group, Family Medicine. Service 2026-02-18 at office (POS 11). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Weber Laura
- Member ID
- UHC-07611-10
- Date of birth
- 1944-09-22
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417950
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6926
- Coverage period
- 2022-03-01 to present
- Deductible
- $157.66 of $1,500.0011%
- Out-of-pocket maximum
- $560.70 of $3,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1145537761
- Network
- In network
- Rendering NPI
- 5504708392
- Location
- Phoenix, AZ · TIN 88-8462048
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 36415 | Venipuncture | 59 | 1 | 1 | $20.00 | $12.40 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 2 | $211.00 | $130.82 | — | — | Review |
| Totals | $231.00 | $143.22 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-922975
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017699 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-18: UNKNOWN (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Medical Group (1145537761). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-02-18 13:17
Patient seen for type 2 diabetes mellitus without complications. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-03-06 06:00
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-922975.pdf16 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.