CLM-2026-023458
Harbor Medical Group, Family Medicine. Service 2026-03-17 at office (POS 11). Received 2026-04-30.
Member
Resolved through the identity graph
- Member
- Bradley Weber
- Member ID
- UHC-33663-44
- Date of birth
- 1991-06-17
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-426776
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6741
- Coverage period
- 2023-07-01 to present
- Deductible
- $186.92 of $500.0037%
- Out-of-pocket maximum
- $329.92 of $1,500.0022%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 1145537761
- Network
- In network
- Rendering NPI
- 1970618421
- Location
- Phoenix, AZ · TIN 88-8462048
- 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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $240.00 | $148.80 | — | — | Review |
| 2 | 90471 | Immunization administration | 59 | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $275.00 | $170.50 | — | — | Review |
| Totals | $552.00 | $342.24 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-252782
- 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-003760 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-17: SELECT-EPO (EPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 44 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 Medical Group (1145537761). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-03-17 14:13
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-04-30 02:04
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-30 13:13
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-252782.pdf19 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021081 | 2026-06-02 | Canyon Cardiovascular Associates | $378.00 | Approved |
| CLM-2026-023412 | 2026-04-25 | Cornerstone Internal Medicine Associates | $443.00 | Approved |
| CLM-2026-001251 | 2026-01-09 | Unity Community Hospital | $1,015.00 | Approved |
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
Bundled code pair; modifier 59 not supported by the operative note.