Professional claim · CMS-1500 · EDI 837P
CLM-2026-004074
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-03-26 at office (POS 11). Received 2026-03-29.
Approved
Billed
$723.00
3 lines
Allowed
$448.26
contract rate applied
Plan pays
$428.26
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Kevin Rojas
- Member ID
- UHC-91709-03
- Date of birth
- 1993-01-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428659
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2118
- Coverage period
- 2025-03-01 to present
- Deductible
- $451.17 of $3,500.0013%
- Out-of-pocket maximum
- $26.40 of $7,000.000%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5634350545
- Network
- In network
- Rendering NPI
- 6271180633
- Location
- San Diego, CA · TIN 74-0606761
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $98.00 | $60.76 | $20.00 | $40.76 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $328.00 | $203.36 | $0.00 | $203.36 | Paid |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $297.00 | $184.14 | $0.00 | $184.14 | Paid |
| Totals | $723.00 | $448.26 | $20.00 | $428.26 | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-334427
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003496 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-26: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 3 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 (5634350545). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Internal Medicine Associates2026-03-26 11:40
Patient seen for copd, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$723.00
Plan discount
$274.74
contracted rate
Plan paid
$428.26
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003170 | 2025-12-09 | Pinecrest Physical Therapy | $350.00 | Denied |
| CLM-2026-003169 | 2025-12-09 | Pinecrest Physical Therapy | $350.00 | 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.