CLM-2026-010182
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-01-10 at office (POS 11). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Elijah Allen
- Member ID
- UHC-15522-20
- Date of birth
- 1943-12-01
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408154
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3627
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,673.81 of $2,500.0067%
- Out-of-pocket maximum
- $3,004.96 of $7,500.0040%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2354462238
- Network
- In network
- Rendering NPI
- 4997052442
- Location
- Los Angeles, CA · TIN 17-5866014
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $287.00 | $177.94 | — | — | DeniedCO29 |
| Totals | $287.00 | $177.94 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-649097
- 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-018217 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-10: - (PPO), effective 2021-12-01. | |
| Timely filing | Fail | CO29 | Received 191 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 | Pass | In-network provider Northgate Internal Medicine Associates (2354462238). | |
| 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 Associates2026-01-10 16:28
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-20 05:08
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
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 191 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022599 | 2026-07-05 | Riverside Orthopedic Specialists | $36,204.00 | Needs review |
| CLM-2026-028931 | 2026-02-09 | Riverside Diagnostic Imaging | $3,007.00 | 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
Received after the timely-filing limit.