CLM-2026-007701
Harbor Primary Care Associates, Family Medicine. Service 2025-12-23 at office (POS 11). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Austin Santos
- Member ID
- UHC-34443-43
- Date of birth
- 1978-06-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428042
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group N/A
- Coverage period
- 2025-10-01 to present
- Deductible
- $311.72 of $3,500.009%
- Out-of-pocket maximum
- $2,469.57 of $14,000.0018%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4898939200
- Network
- Out of network
- Rendering NPI
- 2460187984
- Location
- Austin, TX · TIN 23-1128130
- 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 | 90471 | Immunization administration | — | 1 | 1 | $33.00 | $14.85 | — | — | DeniedCO204 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $335.00 | $150.75 | — | — | DeniedCO204 |
| 3 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1,2 | $271.00 | $121.95 | — | — | DeniedCO204 |
| Totals | $639.00 | $287.55 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-385307
- 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-002733 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-23: CORE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 17 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 | Fail | CO204 | Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Primary Care Associates2025-12-23 14:23
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-09 00:58
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029418 | 2025-12-20 | Meadow Bone and Joint Center | $1,734.00 | Approved |
| CLM-2026-015514 | 2026-01-14 | Evergreen Medical Group | $436.00 | 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
No out-of-network benefit on this plan.