CLM-2026-022242
Harbor Medical Group, Internal Medicine. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Rachel Pierce
- Member ID
- none on golden record
- Date of birth
- 1954-08-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404524
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-3939
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,574.05 of $2,500.0063%
- Out-of-pocket maximum
- $990.46 of $10,000.0010%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 1807307867
- Location
- Minneapolis, MN · TIN 55-1189667
- Authorisation / referral
- PA2026959292 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,675.00 | $1,203.75 | — | — | DeniedCO204 |
| Totals | $2,675.00 | $1,203.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-753159
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 4 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002024; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-31: CORE-HMO (HMO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026959292 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 3009343252 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Group2025-12-31 17:13
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-27 02:14
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-27 17:05
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026959292_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-31 to 2026-03-31.
- Itemized billitemized_PA-753159.pdf7 pages
Itemised statement totalling $2675.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-002024; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-31: CORE-HMO (HMO), effective 2024-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 3009343252 is out of network and the HMO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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
No out-of-network benefit on this plan.