CLM-2026-011290
Northgate Primary Care Associates, Family Medicine. Service 2026-08-27 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Sean Alvarado
- Member ID
- UHC-95582-59
- Date of birth
- 1974-11-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401989
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5900
- Coverage period
- 2022-12-01 to 2026-03-19
- Deductible
- $622.99 of $1,000.0062%
- Out-of-pocket maximum
- $239.86 of $2,000.0012%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4637508332
- Network
- Out of network
- Rendering NPI
- 8223394759
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $191.00 | $85.95 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $229.00 | $103.05 | — | — | DeniedCO27 |
| Totals | $420.00 | $189.00 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-377691
- 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-016927 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-27 is after coverage terminated on 2026-03-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Primary Care Associates2026-08-27 12:53
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-24 05:48
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-24 15:42
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-27 is after coverage terminated on 2026-03-19. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007228 | 2026-09-15 | Mesa Family Practice | $422.00 | Denied |
| CLM-2026-016181 | 2026-02-27 | Sunrise Cardiovascular Associates | $277.00 | 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
Service after coverage termination.