CLM-2026-025157
Harbor Diagnostic Imaging, Radiology. Service 2026-03-08 at outpatient hospital (POS 22). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Dylan Payne
- Member ID
- UHC-58863-01
- Date of birth
- 1958-11-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428596
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2170
- Coverage period
- 2022-02-01 to present
- Deductible
- $392.23 of $1,000.0039%
- Out-of-pocket maximum
- $47.14 of $4,000.001%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
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 / REF635953
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 | $591.00 | $325.05 | $325.05 | $0.00 | Paid |
| Totals | $591.00 | $325.05 | $325.05 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-435268
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019503 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-08: CORE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 5 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 Imaging2026-03-08 15:28
Patient seen for pain in right knee. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-13 06:35
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)2026-03-13 11:47
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-435268.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-435268.pdf7 pages
Itemised statement totalling $591.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
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
Authorisation must be confirmed with UM before payment.