CLM-2026-007244
Northgate Clinical Laboratories, Clinical Laboratory. Service 2025-11-26 at independent laboratory (POS 81). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Kathryn Robinson
- Member ID
- UHC-69124-67
- Date of birth
- 1968-05-13
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-419901
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7620
- Coverage period
- 2022-01-01 to present
- Deductible
- $155.45 of $500.0031%
- Out-of-pocket maximum
- $50.86 of $2,000.003%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9874235952
- Network
- In network
- Rendering NPI
- 9874235952
- Location
- Charlotte, NC · TIN 55-1691702
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $74.00 | $45.88 | — | — | DeniedCO29 |
| Totals | $74.00 | $45.88 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-221450
- 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-003509 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-11-26: - (PPO), effective 2022-01-01. | |
| Timely filing | Fail | CO29 | Received 177 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 Clinical Laboratories (9874235952). | |
| 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 Clinical Laboratories2025-11-26 13:05
Patient seen for urinary tract infection, site not specified.
- SystemSystem: Claims system2026-05-22 06:26
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 177 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021341 | 2026-08-27 | Canyon GI Associates | $2,417.00 | Denied |
| CLM-2026-025409 | 2026-05-12 | Canyon Medical Group | $387.00 | Approved |
| CLM-2026-008822 | 2026-01-04 | Desert Reference Lab | $114.00 | 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
Received after the timely-filing limit.