CLM-2026-008247
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-07-10 at office (POS 11). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Madison Walsh
- Member ID
- UHC-76889-17
- Date of birth
- 1943-07-16
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417992
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3160
- Coverage period
- 2025-09-01 to present
- Deductible
- $873.82 of $3,500.0025%
- Out-of-pocket maximum
- $1,089.84 of $7,000.0016%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5634350545
- Network
- In network
- Rendering NPI
- 7523901982
- Location
- San Diego, CA · TIN 74-0606761
- 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 | $294.00 | $182.28 | — | — | DeniedCO18 |
| Totals | $294.00 | $182.28 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-156916
- 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-035556 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-10: SELECT-EPO (EPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 49 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-008246: 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 (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 Associates2026-07-10 09:58
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-08-28 06:53
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-28 14:53
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 12:44Duplicate check: Exact duplicate of CLM-2026-008246: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008246 | 2026-07-10 | Northgate Internal Medicine Associates | $294.00 | 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.