Claims workbench/CLM-2026-016280

Institutional claim · UB-04 · Paper

CLM-2026-016280

Harbor Regional Medical Center, Emergency Medicine. Service 2026-05-27 at emergency room (POS 23). Received 2026-07-06.

Denied

Billed

$195.00

1 line

Allowed

$107.25

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Kenneth Ray
Member ID: UHC-87282-25
Date of birth: 1965-07-14
Identity: Verified5 records, confidence 0.96
Claim record: CLMCLM-429364
Relationship: Self, Orlando, FL

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-7632
Coverage period: 2025-02-01 to present
Deductible: $272.74 of $1,000.0027%
Out-of-pocket maximum: $304.63 of $4,000.008%
Copays: office $40.00, specialist $50.00, emergency $150.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Harbor Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 9303939968
Network: In network
Rendering NPI: 9303939968
Location: Tempe, AZ · TIN 60-9523328
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	96374 rev 0260	IV push, single drug	—	1	1	$195.00	$107.25	—	—	DeniedCO18
Totals						$195.00	$107.25	—	—

Diagnoses (ICD-10-CM)

1. R55 Syncope and collapseprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-991631
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-022609 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-05-27: OPTIONS-PPO (PPO), effective 2025-02-01.
Timely filing	Pass		Received 40 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-016279: 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 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.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Harbor Regional Medical Center2026-05-27 13:18
Patient seen for syncope and collapse.
SystemSystem: Claims system2026-07-06 00:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-06 13:18
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Itemized billitemized_PA-991631.pdf9 pages
Itemised statement totalling $195.00 across 1 line.
Er reported_report_PA-991631.pdf5 pages
Emergency department record: triage acuity 4, chief complaint syncope and collapse.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Duplicate check: Exact duplicate of CLM-2026-016279: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-016050	2026-07-05	Heritage Internal Medicine Associates	$379.00	Approved
CLM-2026-016279	2026-05-27	Harbor Regional Medical Center	$195.00	Approved
CLM-2026-004460	2026-03-23	Canyon GI Associates	$2,329.00	Approved
CLM-2026-000851	2026-03-17	Valley Bone and Joint Center	$1,536.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity