CLM-2026-013621
Harbor Primary Care Associates, Family Medicine. Service 2026-01-01 at office (POS 11). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Nancy Campbell
- Member ID
- none on golden record
- Date of birth
- 1991-05-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-400017
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-3661
- Coverage period
- 2024-08-01 to present
- Deductible
- $120.21 of $2,500.005%
- Out-of-pocket maximum
- $4,627.78 of $10,000.0046%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4898939200
- Network
- Out of network
- Rendering NPI
- 3048935282
- 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 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $19.35 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $172.00 | $77.40 | — | — | PendedIDQ |
| Totals | $215.00 | $96.75 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-255869
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002343; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-01-01: MEDICARE-ADV-B (MA), effective 2024-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 33 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Primary Care Associates2026-01-01 13:04
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002343; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-01: MEDICARE-ADV-B (MA), effective 2024-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.