CLM-2026-018265
Harbor Imaging Center, Radiology. Service 2026-02-06 at outpatient hospital (POS 22). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Sean Montgomery
- Member ID
- UHC-97339-65
- Date of birth
- 1939-06-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418661
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4664
- Coverage period
- 2025-09-01 to 2026-01-28
- Deductible
- $283.29 of $1,500.0019%
- Out-of-pocket maximum
- $2,218.06 of $4,500.0049%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 3423421452
- Network
- In network
- Rendering NPI
- 3423421452
- Location
- Denver, CO · TIN 47-9293451
- 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $346.00 | $190.30 | — | — | DeniedCO27 |
| Totals | $346.00 | $190.30 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-150326
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-012575 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-06 is after coverage terminated on 2026-01-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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 Imaging Center (3423421452). | |
| 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 Imaging Center2026-02-06 17:34
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-02-12 00:44
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-12 09:54
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-150326.pdf3 pages
Itemised statement totalling $346.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-06 is after coverage terminated on 2026-01-28.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.