CLM-2026-024356
Harbor Primary Care Associates, Family Medicine. Service 2026-05-11 at office (POS 11). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Amber Salazar
- Member ID
- none on golden record
- Date of birth
- 1962-12-17
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-410504
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-5812
- Coverage period
- 2024-01-01 to present
- Deductible
- $252.94 of $500.0051%
- Out-of-pocket maximum
- $283.65 of $1,000.0028%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6839311837
- Network
- In network
- Rendering NPI
- 6935666415
- Location
- Minneapolis, MN · TIN 50-2546964
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $282.00 | $174.84 | $20.00 | $154.84 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $18.00 | $11.16 | $0.00 | $11.16 | Paid |
| Totals | $300.00 | $186.00 | $20.00 | $166.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-855930
- 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-010957 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-05-11: CORE-HMO (HMO), effective 2024-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 20 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 Primary Care Associates (6839311837). | |
| 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 Primary Care Associates2026-05-11 17:35
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2026-05-11: CORE-HMO (HMO), effective 2024-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
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.