CLM-2026-032145
Harbor Regional Medical Center, Emergency Medicine. Service 2026-09-14 at emergency room (POS 23). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Santiago Thompson
- Member ID
- UHC-18101-93
- Date of birth
- 1966-09-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411695
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9062
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,159.06 of $2,500.0046%
- Out-of-pocket maximum
- $2,015.23 of $7,500.0027%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 9303939968
- Network
- In network
- Rendering NPI
- 9303939968
- Location
- Tempe, AZ · TIN 60-9523328
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99283 rev 0450 | Emergency department visit, moderate severity | — | 1 | 1 | $850.00 | $467.50 | $350.00 | $117.50 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 2 | $244.00 | $134.20 | $0.00 | $134.20 | Paid |
| 3 | 99284 rev 0450 | Emergency department visit, high severity | 25 | 1 | 2 | $1,363.00 | $749.65 | $0.00 | $749.65 | Paid |
| Totals | $2,457.00 | $1,351.35 | $350.00 | $1,001.35 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-213986
- 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-016150 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-14: NULL (PPO), effective 2024-05-01. | |
| 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 Regional Medical Center (9303939968). | |
| 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 Regional Medical Center2026-09-14 17:07
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-213986.pdf2 pages
Itemised statement totalling $2457.00 across 3 lines.
- Er reported_report_PA-213986.pdf3 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.
Explanation of benefits
What the member will see
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010376 | 2026-07-28 | Sunrise Diagnostic Imaging | $3,524.00 | Approved |
| CLM-2026-018439 | 2026-04-18 | Sunrise Digestive Health Center | $315.00 | Approved |
| CLM-2026-001002 | 2026-02-14 | Unity Community Hospital | $420.00 | Needs review |
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.