Professional claim · CMS-1500 · Paper
CLM-2026-016216
Harbor Medical Group, Internal Medicine. Service 2026-01-24 at office (POS 11). Received 2026-02-12.
ApprovedOut of network
Billed
$378.00
1 line
Allowed
$170.10
contract rate applied
Plan pays
$150.10
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Arthur Guzman
- Member ID
- UHC-72382-09
- Date of birth
- 1951-01-13
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-416482
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1172
- Coverage period
- 2021-10-01 to present
- Deductible
- $305.14 of $1,500.0020%
- Out-of-pocket maximum
- $1,438.16 of $3,000.0048%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 3219163599
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $378.00 | $170.10 | $20.00 | $150.10 | Paid |
| Totals | $378.00 | $170.10 | $20.00 | $150.10 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
Claim header
- Patient account
- PA-404041
- 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-012434 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-24: CHOICE-PLUS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 19 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-01-24 16:10
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$378.00
Plan discount
$207.90
out-of-network allowance
Plan paid
$150.10
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002704 | 2026-04-19 | Northgate Clinical Laboratories | $110.00 | Approved |
| CLM-2026-010598 | 2026-01-08 | Sunrise Medical Group | $336.00 | Approved |
| CLM-2026-016217 | 2026-01-24 | Harbor Medical Group | $378.00 | Denied |
| CLM-2026-023826 | 2026-01-22 | Unity Primary Care Associates | $510.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.