CLM-2026-023980
Harbor Diabetes Center, Endocrinology. Service 2026-05-01 at office (POS 11). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Logan Salazar
- Member ID
- UHC-81920-75
- Date of birth
- 2007-03-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412310
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6193
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,000.63 of $2,500.0040%
- Out-of-pocket maximum
- $2,036.44 of $7,500.0027%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Diabetes CenterEndocrinology · taxonomy 207RE0101X
- NPI
- 7519485602
- Network
- In network
- Rendering NPI
- 6441551366
- Location
- Tempe, AZ · TIN 55-9687647
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $198.00 | $122.76 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 1 | $277.00 | $171.74 | — | — | DeniedCO18 |
| Totals | $475.00 | $294.50 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-315563
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017096 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-01: - (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023979: 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 Diabetes Center (7519485602). | |
| 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 Diabetes Center2026-05-01 14:45
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-02 03:29
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-023979: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023979 | 2026-05-01 | Harbor Diabetes Center | $475.00 | Approved |
| CLM-2026-013573 | 2026-04-06 | Canyon Internal Medicine Associates | $388.00 | Approved |
| CLM-2026-003774 | 2026-02-23 | Evergreen Clinical Laboratories | $116.00 | 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.