CLM-2026-033073
Harbor Regional Medical Center, Emergency Medicine. Service 2026-05-24 at emergency room (POS 23). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Ashley Garza
- Member ID
- UHC-69569-85
- Date of birth
- 1971-09-10
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-426936
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6974
- Coverage period
- 2025-08-01 to present
- Deductible
- $229.12 of $500.0046%
- Out-of-pocket maximum
- $158.39 of $1,000.0016%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 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 / REF203672
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 | 99284 rev 0450 | Emergency department visit, high severity | — | 1 | 1 | $1,414.00 | $777.70 | $250.00 | $527.70 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | 25 | 1 | 1 | $170.00 | $93.50 | $0.00 | $93.50 | Paid |
| Totals | $1,584.00 | $871.20 | $250.00 | $621.20 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. J18.9 Pneumonia, unspecified organism
- Patient account
- PA-996052
- 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-029965 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-24: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 11 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 Center2026-05-24 12:30
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-996052.pdf4 pages
Itemised statement totalling $1584.00 across 2 lines.
- Er reported_report_PA-996052.pdf6 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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033635 | 2026-09-27 | Harbor Physical Therapy | $308.00 | Approved |
| CLM-2026-033074 | 2026-05-24 | Sunrise Community Hospital | $1,584.00 | Needs review |
| CLM-2026-031165 | 2026-04-20 | Mesa Diabetes Center | $162.00 | 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.