CLM-2026-015596
Harbor Cardiovascular Associates, Cardiology. Service 2026-08-11 at office (POS 11). Received 2026-10-08.
Member
Resolved through the identity graph
- Member
- Teresa Sims
- Member ID
- UHC-19809-99
- Date of birth
- 1970-02-08
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-429170
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8377
- Coverage period
- 2024-04-01 to present
- Deductible
- $1,113.80 of $1,500.0074%
- Out-of-pocket maximum
- $1,319.18 of $3,000.0044%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1432011819
- Network
- In network
- Rendering NPI
- 8893070549
- Location
- Nashville, TN · TIN 57-5710121
- 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 | $236.00 | $146.32 | — | — | DeniedCO18 |
| Totals | $236.00 | $146.32 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-322400
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-034183 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-11: MEDICARE-ADV-A (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 58 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-015595: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Cardiovascular Associates (1432011819). | |
| 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 Cardiovascular Associates2026-08-11 10:25
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-10-08 02:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-015595: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015595 | 2026-08-11 | Harbor Cardiovascular Associates | $236.00 | Approved |
| CLM-2026-022159 | 2026-07-15 | Canyon Reference Lab | $110.00 | Approved |
| CLM-2026-005713 | 2026-06-16 | Desert Primary Care Associates | $560.00 | Approved |
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
Exact duplicate of an earlier submission.