CLM-2026-006415
Northgate Medical Group, Family Medicine. Service 2026-04-21 at office (POS 11). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Katherine Butler
- Member ID
- UHC-58714-09
- Date of birth
- 1938-10-05
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-426943
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1841
- Coverage period
- 2025-04-01 to present
- Deductible
- $97.35 of $500.0019%
- Out-of-pocket maximum
- $91.68 of $1,500.006%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6636200761
- Network
- In network
- Rendering NPI
- 2797710722
- 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 | 90471 | Immunization administration | — | 1 | 1 | $39.00 | $24.18 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $213.00 | $132.06 | — | — | DeniedCO18 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $328.00 | $203.36 | — | — | DeniedCO18 |
| Totals | $580.00 | $359.60 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-809064
- 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-004692 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-04-21: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-006414: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Group2026-04-21 12:38
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-19 00:27
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-19 09:26
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-006414: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006414 | 2026-04-21 | Northgate Medical Group | $580.00 | Approved |
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
Exact duplicate of an earlier submission.