CLM-2026-024639
Harbor Primary Care Associates, Family Medicine. Service 2026-04-17 at office (POS 11). Received 2026-04-25.
Member
Resolved through the identity graph
- Member
- Danielle Henry
- Member ID
- UHC-92098-20
- Date of birth
- 1950-11-16
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-425067
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8982
- Coverage period
- 2024-12-01 to present
- Deductible
- $215.43 of $500.0043%
- Out-of-pocket maximum
- $477.93 of $2,000.0024%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6839311837
- Network
- In network
- Rendering NPI
- 1762077976
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | $14.26 | $0.00 | Paid |
| Totals | $23.00 | $14.26 | $14.26 | $0.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-213897
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015401 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-04-17: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 8 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 Associates2026-04-17 11:39
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-04-25 04:12
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-213897.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007059 | 2026-07-18 | Valley Primary Care Associates | $456.00 | Approved |
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
Authorisation must be confirmed with UM before payment.