CLM-2026-027742
Harbor Regional Medical Center, Emergency Medicine. Service 2026-07-18 at emergency room (POS 23). Received 2026-07-30.
Member
Resolved through the identity graph
- Member
- Kevin Willis
- Member ID
- UHC-76668-92
- Date of birth
- 1978-08-28
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-428957
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9538
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,508.35 of $3,500.0043%
- Out-of-pocket maximum
- $22.66 of $7,000.000%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 9303939968
- Network
- In network
- Rendering NPI
- 9303939968
- Location
- Tempe, AZ · TIN 60-9523328
- Authorisation / referral
- none / none
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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,498.00 | $823.90 | — | — | Review |
| 2 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 2 | $1,064.00 | $585.20 | — | — | Review |
| Totals | $2,562.00 | $1,409.10 | — | — | ||||||
- 1. R55 Syncope and collapseprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-362510
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-032740 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-18: MEDICARE-ADV-A (MA), effective 2025-11-01. | |
| Timely filing | Pass | Received 12 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 Regional Medical Center (9303939968). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for syncope and collapse. Plan discussed, medications reconciled. Note dictated;”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Regional Medical Center2026-07-18 14:35
Follow-up for syncope and collapse. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-30 04:32
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-362510.pdf7 pages
Itemised statement totalling $2562.00 across 2 lines.
- Er reported_report_PA-362510.pdf2 pages
Emergency department record: triage acuity 3, chief complaint syncope and collapse.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for syncope and collapse. Plan discussed, medications reconciled. Note dictated;”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.