Claims workbench/CLM-2026-013235

Professional claim · CMS-1500 · EDI 837P

CLM-2026-013235

Harbor Primary Care Associates, Family Medicine. Service 2026-03-22 at office (POS 11). Received 2026-05-04.

DeniedOut of network

Billed

$704.00

3 lines

Allowed

$316.80

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Ana Cunningham
Member ID: UHC-35095-35
Date of birth: 1972-03-03
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-409871
Relationship: Self, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-0960
Coverage period: 2025-05-01 to present
Deductible: $2,086.13 of $2,500.0083%
Out-of-pocket maximum: $1,698.33 of $7,500.0023%
Copays: office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Harbor Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 4898939200
Network: Out of network
Rendering NPI: 8569737710
Location: Austin, TX · TIN 23-1128130
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	99214	Office visit, established patient, moderate complexity	—	1	1	$256.00	$115.20	—	—	DeniedCO204
2	99213	Office visit, established patient, low complexity	—	1	1,2	$198.00	$89.10	—	—	DeniedCO204
3	99395	Preventive visit, 18-39 years	—	1	1,2	$250.00	$112.50	—	—	DeniedCO204
Totals						$704.00	$316.80	—	—

Diagnoses (ICD-10-CM)

1. E78.5 Hyperlipidemia, unspecifiedprincipal
2. J06.9 Acute upper respiratory infection, unspecified

Claim header

Patient account: PA-309883
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-014924 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-03-22: NAVIGATE-HMO (HMO), effective 2025-05-01.
Timely filing	Pass		Received 43 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-013234, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Fail	CO204	Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Harbor Primary Care Associates2026-03-22 09:30
Patient seen for hyperlipidemia, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-05-04 05:13
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-04 17:33
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-013234, billed by a different provider. Provider network: Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-013234	2026-03-22	Meadow Primary Care Associates	$704.00	Approved
CLM-2026-024296	2026-02-11	Summit Clinical Laboratories	$56.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity