CLM-2026-018028
Harbor Medical Group, Internal Medicine. Service 2026-07-18 to 2026-07-20 at inpatient hospital (POS 21). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Janice Riley
- Member ID
- UHC-13352-81
- Date of birth
- 2007-10-04
- Identity
- Verified2 records, confidence 0.94
- Claim record
- CLMCLM-421988
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6210
- Coverage period
- 2021-11-01 to present
- Deductible
- $98.75 of $1,000.0010%
- Out-of-pocket maximum
- $1,324.11 of $3,000.0044%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 9684316422
- Location
- Minneapolis, MN · TIN 55-1189667
- 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 | $167.00 | $75.15 | $75.15 | $0.00 | Paid |
| Totals | $167.00 | $75.15 | $75.15 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-178455
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-18 to 2026-07-19
- 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-032507 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-07-18: MEDICARE-ADV-B (MA), effective 2021-11-01. | |
| Timely filing | Pass | Received 34 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 Group2026-07-20 17:05
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-178455.pdf2 pages
Itemised statement totalling $167.00 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
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.