CLM-2026-004239
Northgate Medical Group, Family Medicine. Service 2026-02-03 at office (POS 11). Received 2026-02-07.
Member
Resolved through the identity graph
- Member
- Nicole Welch
- Member ID
- UHC-08156-10
- Date of birth
- 1975-05-01
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-419840
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8246
- Coverage period
- 2025-09-01 to 2026-01-24
- Deductible
- $1,924.31 of $2,500.0077%
- Out-of-pocket maximum
- $67.03 of $5,000.001%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3539927137
- Network
- In network
- Rendering NPI
- 2508545748
- 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 | 90471 | Immunization administration | — | 1 | 1 | $29.00 | $17.98 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $212.00 | $131.44 | — | — | DeniedCO27 |
| Totals | $241.00 | $149.42 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-192389
- 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-004890 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-03 is after coverage terminated on 2026-01-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Medical Group2026-02-03 16:43
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-02-07 00:13
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-07 13:56
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 12:44Eligibility: Date of service 2026-02-03 is after coverage terminated on 2026-01-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029664 | 2026-06-03 | Evergreen Primary Care Associates | $30.00 | Denied |
| CLM-2026-024120 | 2026-02-19 | Desert Internal Medicine Associates | $380.00 | Denied |
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
Service after coverage termination.