CLM-2026-028944
Harbor Endocrine Associates, Endocrinology. Service 2025-12-18 at office (POS 11). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Brenda Johnston
- Member ID
- UHC-43932-61
- Date of birth
- 1996-01-24
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-404834
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2395
- Coverage period
- 2024-08-01 to present
- Deductible
- $726.21 of $1,500.0048%
- Out-of-pocket maximum
- $1,018.75 of $3,000.0034%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 8826206194
- Network
- In network
- Rendering NPI
- 6620683816
- Location
- Nashville, TN · TIN 64-6622080
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $222.00 | $137.64 | $75.00 | $62.64 | Paid |
| Totals | $222.00 | $137.64 | $75.00 | $62.64 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-748995
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001488 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-18: - (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 18 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 Endocrine Associates (8826206194). | |
| 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 Endocrine Associates2025-12-18 18:59
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030251 | 2026-09-12 | Valley Primary Care Associates | $403.00 | Approved |
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.