CLM-2026-021872
Harbor Regional Medical Center, Emergency Medicine. Service 2026-07-17 at emergency room (POS 23). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Richard Hansen
- Member ID
- UHC-25477-10
- Date of birth
- 1959-10-08
- Identity
- Verified5 records, confidence 0.98
- Claim record
- CLMCLM-423288
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2968
- Coverage period
- 2021-04-01 to present
- Deductible
- $691.92 of $1,500.0046%
- Out-of-pocket maximum
- $361.44 of $4,500.008%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 9303939968
- Network
- In network
- Rendering NPI
- 9303939968
- Location
- Tempe, AZ · TIN 60-9523328
- 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 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $1,097.00 | $603.35 | $250.00 | $353.35 | Paid |
| 2 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 2 | $1,690.00 | $929.50 | $0.00 | $929.50 | Paid |
| Totals | $2,787.00 | $1,532.85 | $250.00 | $1,282.85 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-805306
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011482 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-07-17: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 17 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 Regional Medical Center (9303939968). | |
| 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 Regional Medical Center2026-07-17 10:50
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-805306.pdf2 pages
Itemised statement totalling $2787.00 across 2 lines.
- Er reported_report_PA-805306.pdf2 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029488 | 2026-08-26 | Evergreen Orthopedic Specialists | $208.00 | Approved |
| CLM-2026-020740 | 2026-02-02 | Riverside Regional Medical Center | $201.00 | Approved |
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.