CLM-2026-017102
Harbor Medical Group, Internal Medicine. Service 2026-03-26 to 2026-03-30 at inpatient hospital (POS 21). Received 2026-04-03.
Member
Resolved through the identity graph
- Member
- Harold Rogers
- Member ID
- UHC-54307-35
- Date of birth
- 2005-10-15
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-412351
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group N/A
- Coverage period
- 2024-08-01 to present
- Deductible
- $52.88 of $1,000.005%
- Out-of-pocket maximum
- $365.00 of $4,000.009%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 4108743236
- Location
- Charlotte, NC · TIN 28-8078153
- 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $211.00 | $94.95 | $94.95 | $0.00 | Paid |
| Totals | $211.00 | $94.95 | $94.95 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-136612
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-26 to 2026-03-30
- 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-023681 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-26: MEDICARE-ADV-B (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 4 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-03-30 17:04
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-136612.pdf8 pages
Itemised statement totalling $211.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider 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-2026-018009 | 2026-03-24 | Pinecrest Primary Care Associates | $45.00 | 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.