Professional claim · CMS-1500 · EDI 837P
CLM-2026-003048
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-05-16 at independent laboratory (POS 81). Received 2026-05-21.
Approved
Billed
$159.00
3 lines
Allowed
$98.58
contract rate applied
Plan pays
$0.00
approved
Member owes
$98.58
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Marilyn Miller
- Member ID
- UHC-47254-57
- Date of birth
- 1955-01-17
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-401321
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9014
- Coverage period
- 2021-04-01 to present
- Deductible
- $2,205.40 of $2,500.0088%
- Out-of-pocket maximum
- $1,643.97 of $10,000.0016%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9320502187
- Network
- In network
- Rendering NPI
- 9320502187
- Location
- Miami, FL · TIN 99-9648979
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $66.00 | $40.92 | $40.92 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $44.00 | $27.28 | $27.28 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $49.00 | $30.38 | $30.38 | $0.00 | Paid |
| Totals | $159.00 | $98.58 | $98.58 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-136225
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001763 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-16: CORE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 5 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 Northgate Clinical Laboratories (9320502187). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Clinical Laboratories2026-05-16 15:42
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$159.00
Plan discount
$60.42
contracted rate
Plan paid
$0.00
You may owe
$98.58
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022347 | 2026-06-17 | Harbor Cardiovascular Associates | $6,578.00 | Needs review |
| CLM-2026-028644 | 2026-04-11 | Sunrise Dermatology Clinic | $567.00 | Approved |
| CLM-2026-015279 | 2026-04-09 | Meadow Family Practice | $465.00 | Approved |
| CLM-2026-021770 | 2026-01-27 | Mesa Behavioral Health | $270.00 | Approved |
| CLM-2026-029880 | 2025-12-04 | Northgate Internal Medicine Associates | $289.00 | 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.