CLM-2026-019951
Harbor Primary Care Associates, Family Medicine. Service 2026-01-17 at office (POS 11). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Doris West
- Member ID
- UHC-24341-03
- Date of birth
- 1939-12-09
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-408585
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7328
- Coverage period
- 2023-03-01 to present
- Deductible
- $519.57 of $1,000.0052%
- Out-of-pocket maximum
- $437.15 of $3,000.0015%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6148699500
- Network
- In network
- Rendering NPI
- 7286621793
- Location
- Austin, TX · TIN 83-6744178
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $182.00 | $112.84 | — | — | DeniedCO18 |
| Totals | $182.00 | $112.84 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-546459
- 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-013691 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-17: NAVIGATE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 49 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-019950: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Primary Care Associates (6148699500). | |
| 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 Primary Care Associates2026-01-17 11:09
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-07 01:40
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-07 11:36
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-019950: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019950 | 2026-01-17 | Harbor Primary Care Associates | $182.00 | Approved |
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
Exact duplicate of an earlier submission.