CLM-2026-028465
Harbor Regional Medical Center, Emergency Medicine. Service 2026-02-03 at emergency room (POS 23). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Mariana Henry
- Member ID
- UHC-62911-98
- Date of birth
- 1946-04-24
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-428580
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6260
- Coverage period
- 2023-05-01 to present
- Deductible
- $2,089.39 of $3,500.0060%
- Out-of-pocket maximum
- $1,899.09 of $7,000.0027%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- 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 | $1,473.00 | $810.15 | $250.00 | $560.15 | Paid |
| 2 | 99285 rev 0450 | Emergency department visit, high severity with threat to life | — | 1 | 2 | $2,925.00 | $1,608.75 | $0.00 | $1,608.75 | Paid |
| Totals | $4,398.00 | $2,418.90 | $250.00 | $2,168.90 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. R55 Syncope and collapse
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-309077
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011831 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-03: SELECT-EPO (EPO), effective 2023-05-01. | |
| 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 | 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Regional Medical Center2026-02-03 14:09
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-309077.pdf5 pages
Itemised statement totalling $4398.00 across 2 lines.
- Er reported_report_PA-309077.pdf5 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.