CLM-2026-010315
Harbor Diabetes Center, Endocrinology. Service 2026-02-03 at office (POS 11). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Mary Jacobs
- Member ID
- UHC-68644-16
- Date of birth
- 1983-06-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-413512
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3048
- Coverage period
- 2024-05-01 to present
- Deductible
- $58.58 of $500.0012%
- Out-of-pocket maximum
- $762.22 of $2,000.0038%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 7519485602
- Network
- In network
- Rendering NPI
- 1631326158
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $75.00 | $46.50 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $281.00 | $174.22 | — | — | DeniedCO29 |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $305.00 | $189.10 | — | — | DeniedCO29 |
| Totals | $661.00 | $409.82 | — | — | ||||||
- 1. E05.90 Thyrotoxicosis, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-977272
- 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-000828 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-03: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Fail | CO29 | Received 99 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 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 Center2026-02-03 14:23
Established patient presents with thyrotoxicosis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-13 00:55
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 99 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.