CLM-2026-013027
Harbor Regional Medical Center, Emergency Medicine. Service 2026-07-11 at emergency room (POS 23). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Heather Welch
- Member ID
- UHC-33964-15
- Date of birth
- 1979-04-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409576
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0795
- Coverage period
- 2022-08-01 to present
- Deductible
- $528.36 of $1,000.0053%
- Out-of-pocket maximum
- $22.71 of $4,000.001%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 12 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $145.00 | $79.75 | $79.75 | $0.00 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | — | 1 | 2 | $203.00 | $111.65 | $0.00 | $111.65 | Paid |
| Totals | $348.00 | $191.40 | $79.75 | $111.65 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-495257
- 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-037423 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-11: MEDICARE-ADV-B (MA), effective 2022-08-01. | |
| Timely filing | Pass | Received 44 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 Center2026-07-11 12:13
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-495257.pdf2 pages
Itemised statement totalling $348.00 across 2 lines.
- Er reported_report_PA-495257.pdf4 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
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-2026-003158 | 2026-08-21 | Canyon GI Associates | $215.00 | Approved |
| CLM-2026-032975 | 2026-08-14 | Riverside Regional Medical Center | $3,044.00 | Approved |
| CLM-2026-030957 | 2026-08-08 | Lakeside Physical Therapy | $314.00 | Approved |
| CLM-2026-003995 | 2026-06-11 | Northgate Medical Group | $441.00 | 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.