CLM-2026-016063
Harbor Regional Medical Center, Emergency Medicine. Service 2026-02-22 at emergency room (POS 23). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Hiroshi Tran
- Member ID
- UHC-69597-53
- Date of birth
- 1986-02-04
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-430347
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9926
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,816.71 of $2,500.0073%
- Out-of-pocket maximum
- $617.51 of $7,500.008%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 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 / REF631299
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 | 96374 rev 0260 | IV push, single drug | — | 1 | 1 | $224.00 | $123.20 | $123.20 | $0.00 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,047.00 | $575.85 | $0.00 | $575.85 | Paid |
| Totals | $1,271.00 | $699.05 | $123.20 | $575.85 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-102624
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003751 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-22: CORE-HMO (HMO), effective 2023-04-01. | |
| Timely filing | Pass | Received 43 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 Center2026-02-22 10:46
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-102624.pdf4 pages
Itemised statement totalling $1271.00 across 2 lines.
- Er reported_report_PA-102624.pdf5 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016309 | 2026-02-23 | Desert Diagnostic Imaging | $538.00 | Approved |
| CLM-2026-001153 | 2026-01-02 | Unity Dermatology Clinic | $877.00 | 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.