CLM-2026-006049
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-06-03 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Eric Russell
- Member ID
- UHC-83773-63
- Date of birth
- 1964-12-03
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-427424
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7205
- Coverage period
- 2022-06-01 to 2026-02-27
- Deductible
- $41.87 of $500.008%
- Out-of-pocket maximum
- $940.94 of $2,000.0047%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9124785673
- Network
- In network
- Rendering NPI
- 4617648850
- Location
- Nashville, TN · TIN 42-1533753
- Authorisation / referral
- none / REF698943
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $352.00 | $218.24 | — | — | DeniedCO27 |
| Totals | $352.00 | $218.24 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. J44.9 COPD, unspecified
- Patient account
- PA-845922
- 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-034445 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-03 is after coverage terminated on 2026-02-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Internal Medicine Associates (9124785673). | |
| 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 Internal Medicine Associates2026-06-03 11:07
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-11 04:20
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-11 11:44
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-06-03 is after coverage terminated on 2026-02-27.
Other claims for this member
Same resolved identity
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.