Claims workbench/CLM-2026-008021

Professional claim · CMS-1500 · EDI 837P

CLM-2026-008021

Northgate Primary Care Associates, Family Medicine. Service 2025-08-08 at office (POS 11). Received 2026-02-28.

DeniedOut of network

Billed

$244.00

2 lines

Allowed

$109.80

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29, CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Amy Sanchez
Member ID: UHC-63205-92
Date of birth: 1972-07-02
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-432360
Relationship: Child, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-2838
Coverage period: 2025-08-01 to present
Deductible: $346.42 of $3,500.0010%
Out-of-pocket maximum: $5,065.66 of $14,000.0036%
Copays: office $25.00, specialist $75.00, emergency $350.00
Physical therapy visits: 21 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 4637508332
Network: Out of network
Rendering NPI: 7395817589
Location: Minneapolis, MN · TIN 67-8207814
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	36415	Venipuncture	—	1	1	$13.00	$5.85	—	—	DeniedCO29
2	99395	Preventive visit, 18-39 years	—	1	1,2	$231.00	$103.95	—	—	DeniedCO29
Totals						$244.00	$109.80	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal
2. Z00.00 Encounter for general adult medical examination without abnormal findings

Claim header

Patient account: PA-940910
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-015480 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-08-08: CORE-HMO (HMO), effective 2025-08-01.
Timely filing	Fail	CO29	Received 204 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	Fail	CO204	Billing provider 4637508332 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Primary Care Associates2025-08-08 18:25
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-02-28 01:57
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

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 204 days after the last date of service (limit 90). Provider network: Billing provider 4637508332 is out of network and the HMO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-019460	2026-05-17	Riverside Primary Care Associates	$181.00	Approved
CLM-2026-006438	2026-04-12	Lakeside Medical Group	$423.00	Denied
CLM-2026-016108	2026-03-10	Northgate Internal Medicine Associates	$3,324.00	Needs review
CLM-2026-002954	2026-03-27	Unity Primary Care Associates	$306.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity