CLM-2026-007628
Harbor Diabetes Center, Endocrinology. Service 2026-05-29 at office (POS 11). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Nicholas Romero
- Member ID
- UHC-10303-10
- Date of birth
- 1978-12-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-407351
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5800
- Coverage period
- 2022-03-01 to present
- Deductible
- $145.41 of $1,000.0015%
- Out-of-pocket maximum
- $1,173.50 of $3,000.0039%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 7519485602
- Network
- In network
- Rendering NPI
- 2493571832
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $362.00 | $224.44 | — | — | Review |
| Totals | $362.00 | $224.44 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-663704
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022274 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-29: MEDICARE-ADV-A (MA), effective 2022-03-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-007627; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 Center2026-05-29 13:15
Patient seen for thyrotoxicosis, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-06-09 05:27
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-007627.pdf1 page
Provider cover letter requesting replacement of CLM-2026-007627.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-007627; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008800 | 2026-08-11 | Meadow Reference Lab | $107.00 | Approved |
| CLM-2026-007627 | 2026-05-29 | Harbor Diabetes Center | $362.00 | Approved |
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
Replacement claim supersedes the original.