CLM-2026-030990
Harbor Medical Group, Internal Medicine. Service 2026-06-28 at office (POS 11). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Elizabeth Greene
- Member ID
- UHC-43618-30
- Date of birth
- 1950-01-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409525
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1488
- Coverage period
- 2022-09-01 to present
- Deductible
- $105.39 of $2,500.004%
- Out-of-pocket maximum
- $599.09 of $7,500.008%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1814896696
- Network
- In network
- Rendering NPI
- 3142183433
- Location
- San Diego, CA · TIN 46-1297771
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $61.00 | $37.82 | — | — | DeniedCO18 |
| Totals | $61.00 | $37.82 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-226233
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008656 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-28: CHOICE-PLUS-PPO (PPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030989: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Medical Group (1814896696). | |
| 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 Group2026-06-28 15:05
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-08 03:31
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-030989: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030989 | 2026-06-28 | Harbor Medical Group | $61.00 | Approved |
| CLM-2026-026677 | 2026-05-24 | Pinecrest Primary Care Associates | $250.00 | 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
Exact duplicate of an earlier submission.