Professional claim · CMS-1500 · Provider portal
CLM-2026-033480
Harbor Primary Care Associates, Family Medicine. Service 2026-04-09 at office (POS 11). Received 2026-04-26.
Approved
Billed
$478.00
3 lines
Allowed
$296.36
contract rate applied
Plan pays
$272.80
approved
Member owes
$23.56
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Billy Armstrong
- Member ID
- UHC-00799-30
- Date of birth
- 1954-11-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402439
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6536
- Coverage period
- 2024-06-01 to present
- Deductible
- $2,047.56 of $2,500.0082%
- Out-of-pocket maximum
- $738.06 of $7,500.0010%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6839311837
- Network
- In network
- Rendering NPI
- 8627681470
- Location
- Minneapolis, MN · TIN 50-2546964
- 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 | 90471 | Immunization administration | — | 1 | 1 | $38.00 | $23.56 | $23.56 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $238.00 | $147.56 | $0.00 | $147.56 | Paid |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $202.00 | $125.24 | $0.00 | $125.24 | Paid |
| Totals | $478.00 | $296.36 | $23.56 | $272.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
Claim header
- Patient account
- PA-993211
- 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-008972 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-09: SELECT-EPO (EPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 17 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 Primary Care Associates (6839311837). | |
| 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 Primary Care Associates2026-04-09 16:38
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$478.00
Plan discount
$181.64
contracted rate
Plan paid
$272.80
You may owe
$23.56
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011563 | 2025-12-19 | Riverside Primary Care Associates | $435.00 | Approved |
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.