CLM-2026-034469
Harbor Endocrine Associates, Endocrinology. Service 2026-03-13 at office (POS 11). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Mariana Montgomery
- Member ID
- UHC-28635-58
- Date of birth
- 1976-07-26
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416908
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9800
- Coverage period
- 2024-09-01 to present
- Deductible
- $49.58 of $500.0010%
- Out-of-pocket maximum
- $330.74 of $1,000.0033%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Endocrine AssociatesEndocrinology · taxonomy 207RE0101X
- NPI
- 8826206194
- Network
- In network
- Rendering NPI
- 1104163757
- Location
- Nashville, TN · TIN 64-6622080
- 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 | 95251 | Continuous glucose monitoring, analysis | — | 1 | 1 | $131.00 | $81.22 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 2 | $233.00 | $144.46 | — | — | DeniedCO18 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $54.00 | $33.48 | — | — | DeniedCO18 |
| Totals | $418.00 | $259.16 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. E05.90 Thyrotoxicosis, unspecified
- Patient account
- PA-843568
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-025224 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-13: CHOICE-PLUS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-034468: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Endocrine Associates (8826206194). | |
| 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 Endocrine Associates2026-03-13 15:33
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-20 05:32
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-034468: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034468 | 2026-03-13 | Harbor Endocrine Associates | $418.00 | Approved |
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
Exact duplicate of an earlier submission.