CLM-2026-011638
Harbor Diagnostic Imaging, Radiology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Harold Hall
- Member ID
- none on golden record
- Date of birth
- 1977-02-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428985
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-5064
- Coverage period
- 2022-04-01 to present
- Deductible
- $417.91 of $2,500.0017%
- Out-of-pocket maximum
- $1,945.95 of $10,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- PA2026480190 / REF908066
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,745.00 | $1,509.75 | — | — | PendedIDQ |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $110.00 | $60.50 | — | — | PendedIDQ |
| Totals | $2,855.00 | $1,570.25 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-151805
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002673; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-08-20: CORE-HMO (HMO), effective 2022-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026480190 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Diagnostic Imaging (1623659319). | |
| 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 Diagnostic Imaging2026-08-20 10:39
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026480190_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-20 to 2026-11-18.
- Itemized billitemized_PA-151805.pdf7 pages
Itemised statement totalling $2855.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002673; payment withheld until the identity is confirmed. Eligibility: Active on 2026-08-20: CORE-HMO (HMO), effective 2022-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.