CLM-2026-010431
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-06-14 at independent laboratory (POS 81). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Wei Jenkins
- Member ID
- UHC-07937-89
- Date of birth
- 1985-01-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409651
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9392
- Coverage period
- 2025-08-01 to 2026-03-14
- Deductible
- $1,228.95 of $2,500.0049%
- Out-of-pocket maximum
- $493.76 of $5,000.0010%
- Copays
- office $40.00, specialist $60.00, 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 | 80061 | Lipid panel | — | 1 | 1 | $42.00 | $26.04 | — | — | DeniedCO27 |
| Totals | $42.00 | $26.04 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-999925
- 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-006545 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-14 is after coverage terminated on 2026-03-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Clinical Laboratories2026-06-14 15:37
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-17 05:56
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-14 is after coverage terminated on 2026-03-14.
Other claims for this member
Same resolved identity
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
Service after coverage termination.