CLM-2026-014864
Harbor Medical Group, Internal Medicine. Service 2026-01-25 to 2026-01-28 at inpatient hospital (POS 21). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Joyce Evans
- Member ID
- UHC-33176-99
- Date of birth
- 1958-08-12
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-423227
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7016
- Coverage period
- 2024-04-01 to present
- Deductible
- $711.46 of $3,500.0020%
- Out-of-pocket maximum
- $1,928.84 of $10,500.0018%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 8675734114
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $244.00 | $109.80 | — | — | DeniedCO204 |
| Totals | $244.00 | $109.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-847129
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-25 to 2026-01-26
- 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-002437 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-25: SELECT-EPO (EPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 5 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 | Fail | CO204 | Billing provider 9527891607 is out of network and the EPO 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-01-28 17:59
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-02 05:21
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-02 16:07
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-847129.pdf7 pages
Itemised statement totalling $244.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 9527891607 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023331 | 2026-08-08 | Riverside Primary Care Associates | $626.00 | Approved |
| CLM-2026-012650 | 2025-12-01 | Riverside Bone and Joint Center | $8,377.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.