CLM-2026-028238
Harbor Medical Group, Internal Medicine. Service 2026-08-18 at office (POS 11). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Hannah Martin
- Member ID
- UHC-93034-52
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426848
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9810
- Coverage period
- 2023-02-01 to present
- Deductible
- $917.74 of $2,500.0037%
- Out-of-pocket maximum
- $4,641.26 of $10,000.0046%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 5413199428
- Location
- Minneapolis, MN · TIN 55-1189667
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $258.00 | $116.10 | — | — | PendedIDQ |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1 | $62.00 | $27.90 | — | — | PendedIDQ |
| Totals | $320.00 | $144.00 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-427430
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002156; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-08-18: UNKNOWN (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 17 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-08-18 15:28
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002156; payment withheld until the identity is confirmed. 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
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
Clean claim, priced at contract rate.