Professional claim · CMS-1500 · EDI 837P
CLM-2026-031686
Harbor Medical Group, Internal Medicine. Service 2026-07-23 at office (POS 11). Received 2026-08-19.
Approved
Billed
$144.00
2 lines
Allowed
$89.28
contract rate applied
Plan pays
$69.28
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Olivia Arnold
- Member ID
- UHC-48489-95
- Date of birth
- 1940-05-23
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-419681
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group NULL
- Coverage period
- 2025-11-01 to present
- Deductible
- $718.95 of $1,500.0048%
- Out-of-pocket maximum
- $2,309.54 of $6,000.0038%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1814896696
- Network
- In network
- Rendering NPI
- 3509433447
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $49.00 | $30.38 | $20.00 | $10.38 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $95.00 | $58.90 | $0.00 | $58.90 | Paid |
| Totals | $144.00 | $89.28 | $20.00 | $69.28 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-926533
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029833 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-23: N/A (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 27 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 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Medical Group2026-07-23 18:02
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$144.00
Plan discount
$54.72
contracted rate
Plan paid
$69.28
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
No other claims.
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.