CLM-2026-005866
Northgate Medical Group, Family Medicine. Service 2026-02-23 at office (POS 11). Received 2026-04-07.
Member
Resolved through the identity graph
- Member
- Brian Reed
- Member ID
- UHC-20399-40
- Date of birth
- 1946-07-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420066
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8454
- Coverage period
- 2021-02-01 to present
- Deductible
- $24.98 of $1,000.002%
- Out-of-pocket maximum
- $1,223.03 of $3,000.0041%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6636200761
- Network
- In network
- Rendering NPI
- 8133620954
- Location
- Mesa, AZ · TIN 30-3649363
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $197.00 | $122.14 | $25.00 | $97.14 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $26.00 | $16.12 | $0.00 | $16.12 | Paid |
| Totals | $223.00 | $138.26 | $25.00 | $113.26 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-775852
- 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-024392 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-23: CORE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 43 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 (6636200761). | |
| 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 Group2026-02-23 15:36
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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
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.