CLM-2026-012416
Harbor Regional Medical Center, Emergency Medicine. Service 2026-04-01 at emergency room (POS 23). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Jacqueline Webb
- Member ID
- UHC-60029-17
- Date of birth
- 1940-04-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409793
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4506
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,084.31 of $3,500.0031%
- Out-of-pocket maximum
- $5,017.96 of $10,500.0048%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 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 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,059.00 | $1,132.45 | $350.00 | $782.45 | Paid |
| Totals | $2,059.00 | $1,132.45 | $350.00 | $782.45 | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-222933
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016322 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-01: SELECT-EPO (EPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 12 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 Center2026-04-01 09:30
Patient seen for syncope and collapse.
Attachments
Documents received with the claim
- Itemized billitemized_PA-222933.pdf3 pages
Itemised statement totalling $2059.00 across 1 line.
- Er reported_report_PA-222933.pdf2 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023557 | 2026-04-12 | Meadow Clinical Laboratories | $223.00 | Approved |
| CLM-2026-009769 | 2026-03-22 | Valley Digestive Health Center | $272.00 | Approved |
| CLM-2026-007544 | 2026-02-09 | Valley Medical Group | $250.00 | 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.