CLM-2026-006718
Harbor Medical Group, Family Medicine. Service 2026-05-11 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Marylyn Garrett
- Member ID
- UHC-31011-55
- Date of birth
- 1941-06-07
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-418820
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4622
- Coverage period
- 2021-03-01 to 2026-02-19
- Deductible
- $819.82 of $3,500.0023%
- Out-of-pocket maximum
- $706.67 of $10,500.007%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8631526927
- Network
- In network
- Rendering NPI
- 4397016575
- Location
- Los Angeles, CA · TIN 48-2346295
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $157.00 | $97.34 | — | — | DeniedCO27 |
| Totals | $157.00 | $97.34 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-173518
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002894 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-11 is after coverage terminated on 2026-02-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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 (8631526927). | |
| 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 Medical Group2026-05-11 17:55
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-06-11 03:59
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-11 08:39
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-11 is after coverage terminated on 2026-02-19.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012230 | 2025-12-03 | Mesa Medical Group | $203.00 | 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
Service after coverage termination.