CLM-2026-004741
Northgate Reference Lab, Clinical Laboratory. Service 2026-08-13 at independent laboratory (POS 81). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Abigail Hicks
- Member ID
- UHC-46842-79
- Date of birth
- 2001-04-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407486
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2410
- Coverage period
- 2023-02-01 to 2026-02-04
- Deductible
- $2,839.23 of $3,500.0081%
- Out-of-pocket maximum
- $464.32 of $7,000.007%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 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 | 87086 | Urine culture | — | 1 | 1 | $47.00 | $29.14 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $52.00 | $32.24 | — | — | DeniedCO27 |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $44.00 | $27.28 | — | — | DeniedCO27 |
| Totals | $143.00 | $88.66 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-587672
- 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-011217 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-13 is after coverage terminated on 2026-02-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 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 (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 Lab2026-08-13 15:18
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-24 06:23
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-13 is after coverage terminated on 2026-02-04.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000352 | 2026-07-04 | Meadow Family Practice | $33.00 | Denied |
| CLM-2026-017372 | 2026-04-09 | Lakeside Reference Lab | $68.00 | 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.