CLM-2026-011785
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-04-21 at independent laboratory (POS 81). Received 2026-04-28.
Member
Resolved through the identity graph
- Member
- Omar Morales
- Member ID
- UHC-01149-88
- Date of birth
- 1965-06-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418651
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9955
- Coverage period
- 2024-06-01 to present
- Deductible
- $170.19 of $1,500.0011%
- Out-of-pocket maximum
- $1,146.03 of $4,500.0025%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7617256269
- Network
- In network
- Rendering NPI
- 7617256269
- Location
- Denver, CO · TIN 27-8863034
- 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 | 87086 | Urine culture | — | 1 | 1 | $62.00 | $38.44 | — | — | DeniedCO18 |
| 2 | 80061 | Lipid panel | — | 1 | 1,2 | $58.00 | $35.96 | — | — | DeniedCO18 |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $68.00 | $42.16 | — | — | DeniedCO18 |
| Totals | $188.00 | $116.56 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-206823
- 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-025895 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-21: MEDICARE-ADV-A (MA), effective 2024-06-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-011784: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Clinical Laboratories (7617256269). | |
| 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 Laboratories2026-04-21 15:17
Established patient presents with urinary tract infection, site not specified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-28 05:04
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-011784: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011784 | 2026-04-21 | Northgate Clinical Laboratories | $188.00 | 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
Exact duplicate of an earlier submission.