CLM-2026-002431
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-06-26 at office (POS 11). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Juan Olson
- Member ID
- UHC-11468-94
- Date of birth
- 1972-07-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401766
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4024
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,529.27 of $3,500.0044%
- Out-of-pocket maximum
- $2,533.97 of $10,500.0024%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 7698360451
- Location
- Charlotte, NC · TIN 84-6447646
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $391.00 | $242.42 | — | — | DeniedCO18 |
| Totals | $391.00 | $242.42 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-187064
- 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-039369 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-26: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002430: 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 Internal Medicine Associates (1858506821). | |
| 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 Internal Medicine Associates2026-06-26 13:56
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-08-12 01:13
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-002430: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004227 | 2026-06-16 | Evergreen Medical Group | $207.00 | Approved |
| CLM-2026-002430 | 2026-06-26 | Northgate Internal Medicine Associates | $391.00 | 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.