CLM-2026-010175
Harbor Medical Group, Internal Medicine. Service 2026-07-30 at office (POS 11). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Anthony Oliver
- Member ID
- UHC-51791-98
- Date of birth
- 1962-09-24
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-427553
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7063
- Coverage period
- 2024-09-01 to 2026-07-10
- Deductible
- $329.63 of $500.0066%
- Out-of-pocket maximum
- $392.40 of $1,500.0026%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1814896696
- Network
- In network
- Rendering NPI
- 7076393629
- Location
- San Diego, CA · TIN 46-1297771
- 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 | $83.00 | $51.46 | — | — | DeniedCO27 |
| Totals | $83.00 | $51.46 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-339366
- 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-010309 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-30 is after coverage terminated on 2026-07-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 (1814896696). | |
| 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 Group2026-07-30 10:47
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 04:47
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-20 13:44
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-30 is after coverage terminated on 2026-07-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029454 | 2026-06-26 | Meadow Regional Medical Center | $132.00 | 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.