CLM-2026-006616
Harbor Diabetes Center, Endocrinology. Service 2026-04-20 at office (POS 11). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Walter Phillips
- Member ID
- UHC-08695-23
- Date of birth
- 1998-10-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-416311
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1288
- Coverage period
- 2021-06-01 to present
- Deductible
- $360.20 of $500.0072%
- Out-of-pocket maximum
- $359.39 of $1,000.0036%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 7519485602
- Network
- In network
- Rendering NPI
- 1880961655
- Location
- Tempe, AZ · TIN 55-9687647
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $251.00 | $155.62 | — | — | DeniedCO18 |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 1 | $52.00 | $32.24 | — | — | DeniedCO18 |
| Totals | $303.00 | $187.86 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-207504
- 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-033467 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-20: - (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 56 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-006615: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Diabetes Center (7519485602). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| 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 Diabetes Center2026-04-20 18:43
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-15 06:42
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-15 08:44
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-006615: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006615 | 2026-04-20 | Harbor Diabetes Center | $303.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.