CLM-2026-005529
Northgate Medical Group, Internal Medicine. Service 2026-09-12 to 2026-09-13 at inpatient hospital (POS 21). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Alexis Price
- Member ID
- UHC-80433-48
- Date of birth
- 1958-09-09
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-421902
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3123
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,055.05 of $1,500.0070%
- Out-of-pocket maximum
- $2,108.93 of $6,000.0035%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 6637494223
- Location
- Dallas, TX · TIN 90-6599797
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $163.00 | $89.65 | $89.65 | $0.00 | Paid |
| Totals | $163.00 | $89.65 | $89.65 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-346938
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-12 to 2026-09-15
- 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-025040 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-12: SELECT-EPO (EPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 28 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 (5749254103). | |
| 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 Group2026-09-13 10:09
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-346938.pdf4 pages
Itemised statement totalling $163.00 across 1 line.
Explanation of benefits
What the member will see
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-2026-032680 | 2026-07-27 | Harbor Medical Group | $43.00 | Denied |
| CLM-2026-003141 | 2026-07-25 | Pinecrest GI Associates | $3,594.00 | Approved |
| CLM-2026-001885 | 2026-06-03 | Meadow Clinical Laboratories | $136.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.