CLM-2026-030557
Harbor Primary Care Associates, Family Medicine. Service 2026-09-24 at office (POS 11). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Samuel Marquez
- Member ID
- UHC-23159-56
- Date of birth
- 1995-12-04
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-419864
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7035
- Coverage period
- 2023-11-01 to present
- Deductible
- $494.52 of $1,500.0033%
- Out-of-pocket maximum
- $1,966.49 of $4,500.0044%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6839311837
- Network
- In network
- Rendering NPI
- 2304568332
- Location
- Minneapolis, MN · TIN 50-2546964
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $174.00 | $107.88 | $20.00 | $87.88 | Paid |
| Totals | $174.00 | $107.88 | $20.00 | $87.88 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-559944
- 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-011574 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-24: MEDICARE-ADV-A (MA), effective 2023-11-01. | |
| Timely filing | Pass | Received 13 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 (6839311837). | |
| 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 Primary Care Associates2026-09-24 17:46
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-2026-011183 | 2026-06-08 | Cornerstone Internal Medicine Associates | $67.00 | Denied |
| CLM-2026-011182 | 2026-06-08 | Cornerstone Internal Medicine Associates | $67.00 | Approved |
| CLM-2026-020827 | 2026-02-01 | Riverside Community Hospital | $149.00 | 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.