CLM-2026-007313
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-03-31 to 2026-04-03 at inpatient hospital (POS 21). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Vincent Torres
- Member ID
- UHC-83147-93
- Date of birth
- 1943-05-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406948
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0410
- Coverage period
- 2024-09-01 to 2026-07-22
- Deductible
- $684.34 of $1,500.0046%
- Out-of-pocket maximum
- $1,799.56 of $6,000.0030%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5634350545
- Network
- In network
- Rendering NPI
- 7594152655
- Location
- San Diego, CA · TIN 74-0606761
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $243.00 | $133.65 | $133.65 | $0.00 | Paid |
| Totals | $243.00 | $133.65 | $133.65 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. J44.9 COPD, unspecified
- Patient account
- PA-757780
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-31 to 2026-04-01
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025867 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-31: MEDICARE-ADV-A (MA), effective 2024-09-01, terms 2026-07-22. | |
| Timely filing | Pass | Received 11 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 (5634350545). | |
| 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 Associates2026-04-03 14:29
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-757780.pdf7 pages
Itemised statement totalling $243.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015102 | 2026-08-19 | Mesa Medical Group | $528.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.