CLM-2026-017330
Harbor Endocrine Associates, Endocrinology. Service 2026-01-01 at office (POS 11). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Andrew Lee
- Member ID
- UHC-17562-92
- Date of birth
- 1991-10-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-412061
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8410
- Coverage period
- 2021-05-01 to present
- Deductible
- $124.80 of $1,000.0012%
- Out-of-pocket maximum
- $1,120.91 of $3,000.0037%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 8826206194
- Network
- In network
- Rendering NPI
- 7628560782
- Location
- Nashville, TN · TIN 64-6622080
- 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 | 59 | 1 | 1 | $228.00 | $141.36 | — | — | Review |
| 2 | 83036 | Hemoglobin A1c | 59 | 1 | 1 | $64.00 | $39.68 | — | — | Review |
| Totals | $292.00 | $181.04 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-465168
- 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-001741 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-01: MEDICARE-ADV-A (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 5 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 Endocrine Associates (8826206194). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Endocrine Associates2026-01-01 13:37
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-06 03:26
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-06 10:18
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-465168.pdf20 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-21 14:15The claim is for an office visit and a Hemoglobin A1c test, both of which are covered under the member's plan. The provider is in-network, and the member is eligible. The claim passed all deterministic rules checks except for the NCCI edit, which was flagged due to the use of modifier 59 on a normally bundled code pair. However, the clinical note and operative note provided in the attachments confirm that the procedures were performed at distinct anatomical sites, justifying the use of modifier 59. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · baf21730
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an office visit and a Hemoglobin A1c test, both of which are covered under the member's plan. The provider is in-network, and the member is eligible. The claim passed all deterministic rules checks except for the NCCI edit, which was flagged due to the use of modifier 59 on a normally bundled code pair. However, the clinical note and operative note provided in the attachments confirm that the procedures were performed at distinct anatomical sites, justifying the use of modifier 59. Therefore, the claim is approved.
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
Modifier 59 supported: distinct anatomical site documented.