CLM-2026-028535
Harbor Medical Group, Internal Medicine. Service 2026-08-20 at office (POS 11). Received 2026-09-28.
Member
Resolved through the identity graph
- Member
- Nathan Peters
- Member ID
- UHC-70952-79
- Date of birth
- 1984-03-14
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-429165
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3682
- Coverage period
- 2022-09-01 to present
- Deductible
- $682.32 of $1,500.0045%
- Out-of-pocket maximum
- $1,043.67 of $6,000.0017%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 5968530852
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $402.00 | $180.90 | — | — | DeniedCO204 |
| Totals | $402.00 | $180.90 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-570759
- 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-003072 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: SELECT-EPO (EPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 39 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 3009343252 is out of network and the EPO 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 Medical Group2026-08-20 18:17
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-09-28 06:07
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
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 3009343252 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024061 | 2026-07-18 | Lakeside Medical Group | $436.00 | Needs review |
| CLM-2026-024060 | 2026-07-18 | Lakeside Internal Medicine Associates | $436.00 | Approved |
| CLM-2026-028048 | 2025-12-31 | Lakeside Bone and Joint Center | $481.00 | Approved |
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.