Professional claim · CMS-1500 · EDI 837P
CLM-2026-004462
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-03-14 at independent laboratory (POS 81). Received 2026-04-21.
Approved
Billed
$249.00
4 lines
Allowed
$154.38
contract rate applied
Plan pays
$0.00
approved
Member owes
$154.38
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
- Raymond Banks
- Member ID
- UHC-72994-01
- Date of birth
- 1966-04-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-414142
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5869
- Coverage period
- 2023-04-01 to 2026-08-26
- Deductible
- $243.50 of $1,500.0016%
- Out-of-pocket maximum
- $701.34 of $3,000.0023%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9320502187
- Network
- In network
- Rendering NPI
- 9320502187
- Location
- Miami, FL · TIN 99-9648979
- 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 | 87086 | Urine culture | — | 1 | 1 | $33.00 | $20.46 | $20.46 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $58.00 | $35.96 | $35.96 | $0.00 | Paid |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 1 | $78.00 | $48.36 | $48.36 | $0.00 | Paid |
| 4 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $80.00 | $49.60 | $49.60 | $0.00 | Paid |
| Totals | $249.00 | $154.38 | $154.38 | $0.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-585435
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007745 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-14: NULL (PPO), effective 2023-04-01, terms 2026-08-26. | |
| Timely filing | Pass | Received 38 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 Clinical Laboratories (9320502187). | |
| 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 Clinical Laboratories2026-03-14 17:43
Patient seen for urinary tract infection, site not specified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$249.00
Plan discount
$94.62
contracted rate
Plan paid
$0.00
You may owe
$154.38
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025992 | 2026-09-29 | Pinecrest Diagnostic Imaging | $706.00 | Denied |
| CLM-2026-018918 | 2026-05-29 | Lakeside Internal Medicine Associates | $149.00 | Approved |
| CLM-2026-004463 | 2026-03-14 | Northgate Clinical Laboratories | $249.00 | Needs review |
| CLM-2026-006765 | 2026-02-14 | Sunrise Dermatology Clinic | $470.00 | Approved |
| CLM-2026-000921 | 2025-12-17 | Lakeside Reference Lab | $64.00 | 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.