CLM-2026-028153
Harbor Primary Care Associates, Family Medicine. Service 2026-01-31 at office (POS 11). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Danielle Peterson
- Member ID
- UHC-54962-64
- Date of birth
- 1949-01-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-417153
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7114
- Coverage period
- 2025-02-01 to present
- Deductible
- $64.88 of $1,000.006%
- Out-of-pocket maximum
- $1,772.93 of $4,000.0044%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4898939200
- Network
- Out of network
- Rendering NPI
- 2846867663
- 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 | 90471 | Immunization administration | — | 1 | 1 | $36.00 | $16.20 | — | — | DeniedCO204 |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $18.00 | $8.10 | — | — | DeniedCO204 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $218.00 | $98.10 | — | — | DeniedCO204 |
| Totals | $272.00 | $122.40 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-808174
- 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-010893 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-31: NAVIGATE-HMO (HMO), effective 2025-02-01. | |
| Timely filing | Pass | Received 9 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 | Fail | CO204 | Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-01-31 13:46
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-02-09 00:54
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-02-09 14:44
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 4898939200 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.