CLM-2026-003351
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-08-25 to 2026-08-26 at inpatient hospital (POS 21). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Amy Simpson
- Member ID
- none on golden record
- Date of birth
- 1940-12-05
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-424449
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 7170647268
- Location
- Charlotte, NC · TIN 84-6447646
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $235.00 | $129.25 | — | — | PendedN30 |
| Totals | $235.00 | $129.25 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-164028
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-25 to 2026-08-29
- 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-009814 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 38 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 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 Associates2026-08-26 16:19
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-164028.pdf9 pages
Itemised statement totalling $235.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003352 | 2026-08-25 | Northgate Internal Medicine Associates | $235.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.