CLM-2026-012949
Harbor Medical Group, Family Medicine. Service 2025-10-09 at office (POS 11). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- Lawrence Edwards
- Member ID
- UHC-37501-93
- Date of birth
- 2003-09-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414391
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9444
- Coverage period
- 2025-01-01 to present
- Deductible
- $192.67 of $1,500.0013%
- Out-of-pocket maximum
- $1,159.72 of $4,500.0026%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8631526927
- Network
- In network
- Rendering NPI
- 6261040656
- Location
- Los Angeles, CA · TIN 48-2346295
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 90471 | Immunization administration | — | 1 | 1 | $33.00 | $20.46 | — | — | DeniedCO29 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $142.00 | $88.04 | — | — | DeniedCO29 |
| Totals | $175.00 | $108.50 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-638197
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-007875 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-09: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Fail | CO29 | Received 109 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Medical Group (8631526927). | |
| 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 Group2025-10-09 12:49
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-26 03:37
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-26 08:42
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 109 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.