CLM-2026-006508
Northgate Reference Lab, Clinical Laboratory. Service 2026-03-11 at independent laboratory (POS 81). Received 2026-04-03.
Member
Resolved through the identity graph
- Member
- Cheryl Griffin
- Member ID
- UHC-95521-19
- Date of birth
- 1971-06-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-408527
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5912
- Coverage period
- 2021-11-01 to 2026-01-16
- Deductible
- $172.68 of $500.0035%
- Out-of-pocket maximum
- $195.69 of $1,500.0013%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 15 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $86.00 | $53.32 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $55.00 | $34.10 | — | — | DeniedCO27 |
| 3 | 80061 | Lipid panel | 25 | 1 | 1 | $66.00 | $40.92 | — | — | DeniedCO27 |
| Totals | $207.00 | $128.34 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-835342
- 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-011967 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-11 is after coverage terminated on 2026-01-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 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 Lab2026-03-11 09:14
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-04-03 02:57
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-03 12:46
Called the provider office; awaiting documentation.
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 2026-03-11 is after coverage terminated on 2026-01-16.
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.