CLM-2026-013951
Harbor Regional Medical Center, Emergency Medicine. Service 2026-09-18 at emergency room (POS 23). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Olivia Alvarado
- Member ID
- UHC-69185-07
- Date of birth
- 1999-06-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426329
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-7703
- Coverage period
- 2023-07-01 to present
- Deductible
- $147.72 of $500.0030%
- Out-of-pocket maximum
- $395.67 of $2,000.0020%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 5 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $921.00 | $506.55 | $150.00 | $356.55 | Paid |
| 2 | 96374 rev 0260 | IV push, single drug | 25 | 1 | 1,2 | $182.00 | $100.10 | $0.00 | $100.10 | Paid |
| 3 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1 | $2,516.00 | $1,383.80 | $0.00 | $1,383.80 | Paid |
| Totals | $3,619.00 | $1,990.45 | $150.00 | $1,840.45 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. J18.9 Pneumonia, unspecified organism
- 3. R55 Syncope and collapse
- Patient account
- PA-312939
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027947 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-18: N/A (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 23 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 Center2026-09-18 13:33
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-312939.pdf7 pages
Itemised statement totalling $3619.00 across 3 lines.
- Er reported_report_PA-312939.pdf6 pages
Emergency department record: triage acuity 2, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004456 | 2026-03-27 | Lakeside Physical Therapy | $453.00 | 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.