CLM-2026-033164
Harbor Medical Group, Internal Medicine. Service 2026-08-08 at office (POS 11). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Terry Cunningham
- Member ID
- UHC-10855-14
- Date of birth
- 2007-03-21
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429954
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3411
- Coverage period
- 2025-03-01 to present
- Deductible
- $258.40 of $500.0052%
- Out-of-pocket maximum
- $103.25 of $1,000.0010%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9527891607
- Network
- Out of network
- Rendering NPI
- 7800542962
- Location
- Charlotte, NC · TIN 28-8078153
- Authorisation / referral
- none / REF493478
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $238.00 | $107.10 | — | — | DeniedCO204 |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $90.00 | $40.50 | — | — | DeniedCO204 |
| 3 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1,2 | $55.00 | $24.75 | — | — | DeniedCO204 |
| Totals | $383.00 | $172.35 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-794075
- 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-005448 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-08: CORE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 21 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 9527891607 is out of network and the HMO 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 Group2026-08-08 13:06
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-29 05:36
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
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 9527891607 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008894 | 2026-06-21 | Sunrise Digestive Health Center | $213.00 | Denied |
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.