CLM-2026-011336
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-06-09 at office (POS 11). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Charles Wong
- Member ID
- UHC-46103-78
- Date of birth
- 1963-02-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402202
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3834
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,947.68 of $2,500.0078%
- Out-of-pocket maximum
- $2,280.12 of $7,500.0030%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- 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
- 2935623670
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $94.00 | $58.28 | — | — | Review |
| Totals | $94.00 | $58.28 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-120967
- 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-012512 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-09: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 35 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 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 | Review | CO16 | Documentation incomplete: “Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms re”. 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 Internal Medicine Associates2026-06-09 15:03
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-14 01:14
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-14 12:09
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms re”.
Other claims for this member
Same resolved identity
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.