CLM-2026-007895
Harbor Medical Group, Internal Medicine. Service 2026-08-02 to 2026-08-04 at inpatient hospital (POS 21). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Ruth Meyer
- Member ID
- UHC-88349-27
- Date of birth
- 2004-06-19
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-428128
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3069
- Coverage period
- 2024-09-01 to present
- Deductible
- $583.67 of $2,500.0023%
- Out-of-pocket maximum
- $3,244.70 of $7,500.0043%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 7241779850
- Location
- Minneapolis, MN · TIN 55-1189667
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $207.00 | $93.15 | — | — | DeniedCO204 |
| Totals | $207.00 | $93.15 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-336357
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-02 to 2026-08-03
- 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-016737 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-02: SELECT-EPO (EPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 19 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 3009343252 is out of network and the EPO 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 Medical Group2026-08-04 12:36
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-23 06:12
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
- Itemized billitemized_PA-336357.pdf9 pages
Itemised statement totalling $207.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3009343252 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010270 | 2026-06-16 | Meadow Family Practice | $530.00 | Approved |
| CLM-2026-003182 | 2026-04-29 | Canyon Reference Lab | $77.00 | 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.