CLM-2026-004146
Northgate Reference Lab, Clinical Laboratory. Service 2026-01-12 at independent laboratory (POS 81). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Rachel Coleman
- Member ID
- UHC-34040-77
- Date of birth
- 1949-10-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-412547
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3693
- Coverage period
- 2021-02-01 to present
- Deductible
- $270.00 of $500.0054%
- Out-of-pocket maximum
- $369.69 of $1,000.0037%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7207177792
- Network
- In network
- Rendering NPI
- 7207177792
- Location
- Miami, FL · TIN 47-3638402
- 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 | 80061 | Lipid panel | — | 1 | 1 | $65.00 | $40.30 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $81.00 | $50.22 | — | — | Review |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $35.00 | $21.70 | — | — | Review |
| Totals | $181.00 | $112.22 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-138951
- 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-008858 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: OPTIONS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 22 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 Reference Lab (7207177792). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Reference Lab2026-01-12 16:39
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-03 01:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-03 09:48
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029651 | 2026-09-26 | Desert Internal Medicine Associates | $437.00 | Needs review |
| CLM-2026-033242 | 2026-09-21 | Meadow Reference Lab | $59.00 | Approved |
| CLM-2026-029650 | 2026-09-26 | Desert Internal Medicine Associates | $437.00 | Approved |
| CLM-2026-007664 | 2025-12-16 | Northgate Internal Medicine Associates | $232.00 | Approved |
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
Development letter outstanding.