Professional claim · CMS-1500 · EDI 837P
CLM-2026-030194
Harbor Primary Care Associates, Family Medicine. Service 2026-02-09 at office (POS 11). Received 2026-03-15.
Approved
Billed
$217.00
2 lines
Allowed
$134.54
contract rate applied
Plan pays
$120.28
approved
Member owes
$14.26
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jennifer Pena
- Member ID
- UHC-60009-39
- Date of birth
- 1980-02-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400884
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7196
- Coverage period
- 2023-05-01 to present
- Deductible
- $327.87 of $1,500.0022%
- Out-of-pocket maximum
- $150.32 of $3,000.005%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6148699500
- Network
- In network
- Rendering NPI
- 4368571228
- Location
- Austin, TX · TIN 83-6744178
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | $14.26 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $194.00 | $120.28 | $0.00 | $120.28 | Paid |
| Totals | $217.00 | $134.54 | $14.26 | $120.28 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-711072
- 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-019741 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-09: NAVIGATE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 34 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 Primary Care Associates (6148699500). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Primary Care Associates2026-02-09 10:58
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$217.00
Plan discount
$82.46
contracted rate
Plan paid
$120.28
You may owe
$14.26
copay, deductible and coinsurance
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-2026-016528 | 2026-07-02 | Meadow Physical Therapy | $8,367.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.