Professional claim · CMS-1500 · Paper
CLM-2026-006630
Harbor Medical Group, Internal Medicine. Service 2026-04-10 at office (POS 11). Received 2026-05-09.
ApprovedOut of network
Billed
$52.00
1 line
Allowed
$23.40
contract rate applied
Plan pays
$3.40
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Edward Dunn
- Member ID
- UHC-58248-42
- Date of birth
- 1967-07-08
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-401855
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1890
- Coverage period
- 2024-04-01 to present
- Deductible
- $279.37 of $1,000.0028%
- Out-of-pocket maximum
- $757.69 of $2,000.0038%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 9235910715
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $52.00 | $23.40 | $20.00 | $3.40 | Paid |
| Totals | $52.00 | $23.40 | $20.00 | $3.40 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
Claim header
- Patient account
- PA-891728
- 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-029930 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-10: UNKNOWN (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 29 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-04-10 09:16
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$52.00
Plan discount
$28.60
out-of-network allowance
Plan paid
$3.40
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025027 | 2026-10-01 | Riverside Digestive Health Center | $2,697.00 | Denied |
| CLM-2026-025026 | 2026-10-01 | Riverside Digestive Health Center | $2,697.00 | Approved |
| CLM-2026-034291 | 2026-05-12 | Summit Regional Medical Center | $1,661.00 | Approved |
| CLM-2026-019785 | 2026-04-25 | Valley Skin Care Associates | $233.00 | Needs review |
| CLM-2026-019784 | 2026-04-25 | Sunrise Skin Care Associates | $233.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.