CLM-2026-016727
Harbor Medical Group, Internal Medicine. Service 2026-07-19 at office (POS 11). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Scott Ward
- Member ID
- UHC-51264-75
- Date of birth
- 2005-02-15
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-425801
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3172
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,424.18 of $2,500.0057%
- Out-of-pocket maximum
- $1,690.07 of $10,000.0017%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 2545557144
- Location
- Minneapolis, MN · TIN 55-1189667
- Authorisation / referral
- none / REF621806
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 | $267.00 | $120.15 | — | — | DeniedCO204 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $416.00 | $187.20 | — | — | DeniedCO204 |
| Totals | $683.00 | $307.35 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-621199
- 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-034553 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-07-19: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 29 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 | Fail | CO204 | Billing provider 3009343252 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2026-07-19 18:02
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-17 05:47
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-17 16:02
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 3009343252 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010358 | 2026-05-10 | Lakeside Behavioral Health | $415.00 | Denied |
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
No out-of-network benefit on this plan.