CLM-2026-007716
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-08-23 at office (POS 11). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Jacqueline Mitchell
- Member ID
- UHC-85622-08
- Date of birth
- 1984-06-10
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-427702
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0807
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,928.13 of $2,500.0077%
- Out-of-pocket maximum
- $2,471.73 of $5,000.0049%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 2549289561
- Location
- Charlotte, NC · TIN 84-6447646
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $298.00 | $184.76 | — | — | DeniedCO18 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $52.00 | $32.24 | — | — | DeniedCO18 |
| Totals | $350.00 | $217.00 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-862355
- 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-016059 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-23: OPTIONS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 56 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-007715: 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 Internal Medicine Associates (1858506821). | |
| 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 Associates2026-08-23 10:34
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-18 03:01
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-007715: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007715 | 2026-08-23 | Northgate Internal Medicine Associates | $350.00 | Approved |
| CLM-2026-031746 | 2026-08-11 | Unity Community Hospital | $2,315.00 | 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.