CLM-2026-016341
Harbor Medical Group, Family Medicine. Service 2026-01-17 at office (POS 11). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Margaret Nichols
- Member ID
- UHC-49860-99
- Date of birth
- 1969-01-18
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-418291
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8434
- Coverage period
- 2022-03-01 to present
- Deductible
- $1,490.43 of $3,500.0043%
- Out-of-pocket maximum
- $1,888.81 of $7,000.0027%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8631526927
- Network
- In network
- Rendering NPI
- 4652456409
- Location
- Los Angeles, CA · TIN 48-2346295
- 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 | 90471 | Immunization administration | — | 1 | 1 | $37.00 | $22.94 | $22.94 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $191.00 | $118.42 | $0.00 | $118.42 | Paid |
| Totals | $228.00 | $141.36 | $22.94 | $118.42 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-523877
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009004 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-17: CORE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 14 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 Medical Group (8631526927). | |
| 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 Group2026-01-17 13:35
Patient seen for hyperlipidemia, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-31 04:16
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-31 15:47
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-523877.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
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
Authorisation must be confirmed with UM before payment.