CLM-2026-017266
Harbor Digestive Health Center, Gastroenterology. Service 2026-06-05 at office (POS 11). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Sean Morgan
- Member ID
- UHC-75819-92
- Date of birth
- 2005-10-24
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-419712
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5304
- Coverage period
- 2023-12-01 to present
- Deductible
- $167.18 of $500.0033%
- Out-of-pocket maximum
- $508.69 of $2,000.0025%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 8035057446
- Location
- Tempe, AZ · TIN 89-3478747
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $256.00 | $158.72 | — | — | Review |
| Totals | $256.00 | $158.72 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-255464
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004391 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-05: OPTIONS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 19 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 Digestive Health Center (7922422671). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for epigastric pain. Plan discussed, medications reconciled. Note dictated; sign”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Digestive Health Center2026-06-05 11:54
Follow-up for epigastric pain. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-24 01:07
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-24 16:47
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for epigastric pain. Plan discussed, medications reconciled. Note dictated; sign”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024587 | 2026-08-28 | Evergreen Medical Group | $280.00 | Approved |
| CLM-2026-031928 | 2026-06-12 | Lakeside Endocrine Associates | $189.00 | Approved |
| CLM-2026-013575 | 2025-12-16 | Evergreen Family Practice | $216.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.