Professional claim · CMS-1500 · Provider portal
CLM-2026-012958
Harbor Medical Group, Internal Medicine. Service 2026-09-02 at office (POS 11). Received 2026-09-15.
ApprovedOut of network
Billed
$651.00
3 lines
Allowed
$292.95
contract rate applied
Plan pays
$272.95
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Joan Edwards
- Member ID
- UHC-88614-34
- Date of birth
- 1956-07-06
- Identity
- Verified7 records, confidence 0.98
- Claim record
- CLMCLM-422144
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2620
- Coverage period
- 2022-12-01 to present
- Deductible
- $648.33 of $1,000.0065%
- Out-of-pocket maximum
- $1,815.32 of $4,000.0045%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 9087948631
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $337.00 | $151.65 | $20.00 | $131.65 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $250.00 | $112.50 | $0.00 | $112.50 | Paid |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $64.00 | $28.80 | $0.00 | $28.80 | Paid |
| Totals | $651.00 | $292.95 | $20.00 | $272.95 | ||||||
Diagnoses (ICD-10-CM)
- 1. I48.91 Unspecified atrial fibrillationprincipal
Claim header
- Patient account
- PA-765296
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008807 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-02: NULL (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 13 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-09-02 10:40
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$651.00
Plan discount
$358.05
out-of-network allowance
Plan paid
$272.95
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012959 | 2026-09-02 | Harbor Medical Group | $651.00 | Needs review |
| CLM-2026-020043 | 2025-12-27 | Mesa Internal Medicine Associates | $187.00 | Denied |
| CLM-2026-009289 | 2026-03-29 | Mesa Clinical Laboratories | $126.00 | Approved |
| CLM-2026-008233 | 2026-05-03 | Lakeside Medical Group | $333.00 | Approved |
| CLM-2026-009611 | 2026-04-10 | Heritage Imaging Center | $385.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.