CLM-2026-015072
Harbor Medical Group, Internal Medicine. Service 2026-08-10 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Aisha Franklin
- Member ID
- UHC-04040-01
- Date of birth
- 2005-11-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-405427
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0424
- Coverage period
- 2023-11-01 to present
- Deductible
- $1,765.14 of $2,500.0071%
- Out-of-pocket maximum
- $269.33 of $10,000.003%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 7188673868
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | $266.00 | $119.70 | $20.00 | $99.70 | Paid |
| Totals | $266.00 | $119.70 | $20.00 | $99.70 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-791225
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-041618 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-10: CHOICE-PLUS-PPO (PPO), effective 2023-11-01. | |
| 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 | 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 Medical Group2026-08-10 10:03
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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
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.