CLM-2026-011731
Harbor Regional Medical Center, Emergency Medicine. Service 2025-12-22 at emergency room (POS 23). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Alexander Rose
- Member ID
- UHC-33854-74
- Date of birth
- 1978-06-08
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-406657
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1269
- Coverage period
- 2025-08-01 to present
- Deductible
- $720.59 of $1,000.0072%
- Out-of-pocket maximum
- $529.37 of $2,000.0026%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 9303939968
- Network
- In network
- Rendering NPI
- 9303939968
- Location
- Tempe, AZ · TIN 60-9523328
- 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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,586.00 | $872.30 | $250.00 | $622.30 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $177.00 | $97.35 | $0.00 | $97.35 | Paid |
| Totals | $1,763.00 | $969.65 | $250.00 | $719.65 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-283346
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001320 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-22: SELECT-EPO (EPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 14 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 Regional Medical Center (9303939968). | |
| 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 Regional Medical Center2025-12-22 18:57
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-283346.pdf2 pages
Itemised statement totalling $1763.00 across 2 lines.
- Er reported_report_PA-283346.pdf2 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033094 | 2026-10-12 | Evergreen Orthopedic Specialists | $3,192.00 | Needs review |
| CLM-2026-018836 | 2026-01-19 | Valley Bone and Joint Center | $7,605.00 | Denied |
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.