Professional claim · CMS-1500 · EDI 837P
CLM-2026-026513
Harbor Primary Care Associates, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-05-18.
DeniedOut of network
Billed
$176.00
2 lines
Allowed
$79.20
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Don Taylor
- Member ID
- UHC-78843-89
- Date of birth
- 2000-01-13
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-409134
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2146
- Coverage period
- 2021-02-01 to 2026-04-07
- Deductible
- $244.94 of $500.0049%
- Out-of-pocket maximum
- $248.03 of $1,000.0025%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4898939200
- Network
- Out of network
- Rendering NPI
- 2526601937
- Location
- Austin, TX · TIN 23-1128130
- 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 | $21.00 | $9.45 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $155.00 | $69.75 | — | — | DeniedCO27 |
| Totals | $176.00 | $79.20 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-923381
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031243 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-12 is after coverage terminated on 2026-04-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Primary Care Associates2026-05-12 17:42
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-05-18 02:51
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-12 is after coverage terminated on 2026-04-07. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020084 | 2026-07-09 | Desert Imaging Center | $3,050.00 | 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.