CLM-2026-032340
Harbor Medical Group, Internal Medicine. Service 2026-08-26 to 2026-08-28 at inpatient hospital (POS 21). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Logan Washington
- Member ID
- UHC-85073-69
- Date of birth
- 1985-09-06
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-422291
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1496
- Coverage period
- 2025-06-01 to present
- Deductible
- $2,817.72 of $3,500.0081%
- Out-of-pocket maximum
- $6,739.09 of $14,000.0048%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3009343252
- Network
- Out of network
- Rendering NPI
- 3220311211
- Location
- Minneapolis, MN · TIN 55-1189667
- 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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $211.00 | $94.95 | — | — | DeniedCO204 |
| Totals | $211.00 | $94.95 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-633732
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-26 to 2026-08-30
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-041803 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-26: SELECT-EPO (EPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 12 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 | Fail | CO204 | Billing provider 3009343252 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2026-08-28 14:53
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-09-09 04:29
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Itemized billitemized_PA-633732.pdf6 pages
Itemised statement totalling $211.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 3009343252 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.