Professional claim · CMS-1500 · EDI 837P
CLM-2026-003357
Northgate Medical Group, Family Medicine. Service 2026-02-09 at office (POS 11). Received 2026-03-18.
Approved
Billed
$278.00
2 lines
Allowed
$172.36
contract rate applied
Plan pays
$159.96
approved
Member owes
$12.40
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jacob Holmes
- Member ID
- none on golden record
- Date of birth
- 1993-04-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401851
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0237
- Coverage period
- 2023-10-01 to 2026-03-10
- Deductible
- $1,022.47 of $2,500.0041%
- Out-of-pocket maximum
- $1,813.51 of $5,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3539927137
- Network
- In network
- Rendering NPI
- 1951282270
- Location
- Scottsdale, AZ · TIN 91-2030165
- 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 | 36415 | Venipuncture | — | 1 | 1 | $20.00 | $12.40 | $12.40 | $0.00 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $258.00 | $159.96 | $0.00 | $159.96 | Paid |
| Totals | $278.00 | $172.36 | $12.40 | $159.96 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-660286
- 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-020574 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-02-09: NULL (PPO), effective 2023-10-01, terms 2026-03-10. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 37 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 Medical Group (3539927137). | |
| 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 Medical Group2026-02-09 17:28
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$278.00
Plan discount
$105.64
contracted rate
Plan paid
$159.96
You may owe
$12.40
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2026-02-09: NULL (PPO), effective 2023-10-01, terms 2026-03-10. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007027 | 2026-02-06 | Canyon Reference Lab | $151.00 | Approved |
| CLM-2026-005062 | 2026-03-07 | Canyon Reference Lab | $237.00 | 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.