CLM-2026-006326
Northgate Reference Lab, Clinical Laboratory. Service 2025-12-10 at independent laboratory (POS 81). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Keith Fox
- Member ID
- UHC-46336-96
- Date of birth
- 1975-03-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428218
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8050
- Coverage period
- 2022-02-01 to present
- Deductible
- $845.19 of $2,500.0034%
- Out-of-pocket maximum
- $1,197.19 of $5,000.0024%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $41.00 | $25.42 | — | — | DeniedCO29 |
| 2 | 87086 | Urine culture | — | 1 | 2 | $50.00 | $31.00 | — | — | DeniedCO29 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $86.00 | $53.32 | — | — | DeniedCO29 |
| Totals | $177.00 | $109.74 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-845473
- 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-008128 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: SELECT-EPO (EPO), effective 2022-02-01. | |
| Timely filing | Fail | CO29 | Received 102 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Lab2025-12-10 16:01
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-03-22 03:02
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-22 16:34
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 12:44Timely filing: Received 102 days after the last date of service (limit 90).
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
Received after the timely-filing limit.