CLM-2026-016835
Harbor Regional Medical Center, Emergency Medicine. Service 2026-01-24 at emergency room (POS 23). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Betty Bennett
- Member ID
- UHC-09862-50
- Date of birth
- 1972-12-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413537
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-0768
- Coverage period
- 2021-05-01 to present
- Deductible
- $445.40 of $1,500.0030%
- Out-of-pocket maximum
- $581.31 of $4,500.0013%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 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 / 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $229.00 | $125.95 | $125.95 | $0.00 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 1,2 | $2,066.00 | $1,136.30 | $0.00 | $1,136.30 | Paid |
| Totals | $2,295.00 | $1,262.25 | $125.95 | $1,136.30 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R55 Syncope and collapse
- Patient account
- PA-405678
- 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-015804 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: UNKNOWN (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 32 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 Center2026-01-24 17:41
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-405678.pdf7 pages
Itemised statement totalling $2295.00 across 2 lines.
- Er reported_report_PA-405678.pdf3 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004882 | 2026-04-25 | Riverside Digestive Health Center | $322.00 | 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.