CLM-2026-008938
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-02-03 at independent laboratory (POS 81). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Rachel Coleman
- Member ID
- UHC-96750-71
- Date of birth
- 1981-12-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416068
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1653
- Coverage period
- 2025-05-01 to present
- Deductible
- $2,139.90 of $2,500.0086%
- Out-of-pocket maximum
- $2,198.14 of $7,500.0029%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9320502187
- Network
- In network
- Rendering NPI
- 9320502187
- Location
- Miami, FL · TIN 99-9648979
- 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 | $67.00 | $41.54 | — | — | Review |
| Totals | $67.00 | $41.54 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- Patient account
- PA-899468
- 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-001283 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-03: N/A (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 26 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 Clinical Laboratories (9320502187). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Clinical Laboratories2026-02-03 11:11
Patient seen for urinary tract infection, site not specified. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-01 04:12
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-01 12:54
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005586 | 2026-08-11 | Harbor Cardiovascular Associates | $304.00 | Needs review |
| CLM-2026-005585 | 2026-08-11 | Unity Cardiovascular Associates | $304.00 | Approved |
| CLM-2026-008596 | 2026-02-14 | Pinecrest Physical Therapy | $469.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.