CLM-2026-022932
Harbor Diagnostic Imaging, Radiology. Service 2026-06-01 at outpatient hospital (POS 22). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Ana Fernandez
- Member ID
- none on golden record
- Date of birth
- 1962-03-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417902
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Harbor Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 1623659319
- Network
- In network
- Rendering NPI
- 1623659319
- Location
- Houston, TX · TIN 54-3766877
- Authorisation / referral
- none / REF668974
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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $415.00 | $228.25 | — | — | PendedIDQ |
| Totals | $415.00 | $228.25 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-279706
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003890; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 22 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 Diagnostic Imaging (1623659319). | |
| 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 Diagnostic Imaging2026-06-01 15:39
Follow-up for pain in right knee. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-23 02:05
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-23 13:13
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-279706.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-279706.pdf9 pages
Itemised statement totalling $415.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003890; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.