CLM-2026-012017
Harbor Regional Medical Center, Emergency Medicine. Service 2026-02-16 at emergency room (POS 23). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Hiroshi Powell
- Member ID
- UHC-87923-96
- Date of birth
- 1951-07-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418527
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5041
- Coverage period
- 2024-07-01 to present
- Deductible
- $441.36 of $3,500.0013%
- Out-of-pocket maximum
- $4,437.90 of $10,500.0042%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $969.00 | $532.95 | $250.00 | $282.95 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $149.00 | $81.95 | $0.00 | $81.95 | Paid |
| 3 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $208.00 | $114.40 | $0.00 | $114.40 | Paid |
| Totals | $1,326.00 | $729.30 | $250.00 | $479.30 | ||||||
- 1. J18.9 Pneumonia, unspecified organismprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-253448
- 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-019418 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-16: CHOICE-PLUS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 34 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 Center2026-02-16 15:42
Patient seen for pneumonia, unspecified organism.
Attachments
Documents received with the claim
- Itemized billitemized_PA-253448.pdf6 pages
Itemised statement totalling $1326.00 across 3 lines.
- Er reported_report_PA-253448.pdf4 pages
Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.
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-2026-007331 | 2026-10-02 | Mesa GI Associates | $348.00 | Approved |
| CLM-2026-002993 | 2026-03-29 | Harbor Medical Group | $289.00 | 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.