CLM-2026-003363
Northgate Reference Lab, Clinical Laboratory. Service 2026-04-07 at independent laboratory (POS 81). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Brenda Lung
- Member ID
- UHC-69208-88
- Date of birth
- 1958-12-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418243
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group N/A
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,294.36 of $2,500.0052%
- Out-of-pocket maximum
- $256.94 of $7,500.003%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2558563716
- Network
- In network
- Rendering NPI
- 2558563716
- Location
- Minneapolis, MN · TIN 36-3280776
- 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 | $75.00 | $46.50 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | 25 | 1 | 2 | $45.00 | $27.90 | — | — | DeniedCO29 |
| Totals | $120.00 | $74.40 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-575370
- 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-038570 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-07: CHOICE-PLUS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Fail | CO29 | Received 100 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Reference Lab (2558563716). | |
| 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 Reference Lab2026-04-07 18:19
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-16 04:03
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-16 13:26
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 engineDenied2026-10-22 12:44Timely filing: Received 100 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.