CLM-2026-011159
Harbor Medical Group, Internal Medicine. Service 2026-05-27 to 2026-05-30 at inpatient hospital (POS 21). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Natalie Chavez
- Member ID
- UHC-93945-67
- Date of birth
- 1950-11-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401167
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7994
- Coverage period
- 2022-10-01 to present
- Deductible
- $802.84 of $2,500.0032%
- Out-of-pocket maximum
- $1,017.25 of $5,000.0020%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 6210841261
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | $252.00 | $113.40 | $113.40 | $0.00 | Paid |
| Totals | $252.00 | $113.40 | $113.40 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-939196
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-27 to 2026-05-28
- 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-026955 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: MEDICARE-ADV-A (MA), effective 2022-10-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Group2026-05-30 17:51
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-939196.pdf4 pages
Itemised statement totalling $252.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029192 | 2026-09-11 | Desert Reference Lab | $98.00 | Approved |
| CLM-2026-023316 | 2026-04-06 | Sunrise Diabetes Center | $344.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.