Professional claim · CMS-1500 · EDI 837P
CLM-2026-026098
Harbor Primary Care Associates, Family Medicine. Service 2026-06-23 at office (POS 11). Received 2026-07-27.
Denied
Billed
$29.00
1 line
Allowed
$17.98
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Virginia Rice
- Member ID
- UHC-60262-09
- Date of birth
- 1942-12-26
- Identity
- Verified5 records, confidence 0.89
- Claim record
- CLMCLM-409627
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8220
- Coverage period
- 2022-01-01 to 2026-05-21
- Deductible
- $284.09 of $500.0057%
- Out-of-pocket maximum
- $693.27 of $1,500.0046%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6839311837
- Network
- In network
- Rendering NPI
- 6792819198
- 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 | 90471 | Immunization administration | — | 1 | 1 | $29.00 | $17.98 | — | — | DeniedCO27 |
| Totals | $29.00 | $17.98 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-516877
- 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-016873 (verified, link confidence 0.89). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-23 is after coverage terminated on 2026-05-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Primary Care Associates2026-06-23 16:16
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-07-27 01:20
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-23 is after coverage terminated on 2026-05-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005073 | 2026-09-23 | Evergreen Counseling Center | $285.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.