CLM-2026-001022
Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-17 at office (POS 11). Received 2026-08-02.
Member
Resolved through the identity graph
- Member
- Amanda Li
- Member ID
- UHC-98440-07
- Date of birth
- 1968-03-22
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-431535
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3121
- Coverage period
- 2023-01-01 to present
- Deductible
- $645.24 of $1,000.0065%
- Out-of-pocket maximum
- $1,370.96 of $4,000.0034%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 6545828207
- Network
- In network
- Rendering NPI
- 1015727435
- Location
- Miami, FL · TIN 98-4961021
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $201.00 | $124.62 | — | — | DeniedCO18 |
| Totals | $201.00 | $124.62 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-820010
- 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-033044 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-17: NAVIGATE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 46 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-001021: 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 Northgate Orthopedic Specialists (6545828207). | |
| 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: Northgate Orthopedic Specialists2026-06-17 10:28
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-08-02 06:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-02 16:02
Called the provider office; awaiting documentation.
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-2026-001021: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031043 | 2026-08-02 | Canyon Skin Care Associates | $449.00 | Approved |
| CLM-2026-009585 | 2026-07-23 | Pinecrest Internal Medicine Associates | $774.00 | Needs review |
| CLM-2026-001021 | 2026-06-17 | Northgate Orthopedic Specialists | $201.00 | Approved |
| CLM-2026-031152 | 2026-05-03 | Desert Diabetes Center | $323.00 | 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.