CLM-2026-011819
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-06-02 at independent laboratory (POS 81). Received 2026-06-16.
Member
Resolved through the identity graph
- Member
- Donald Grant
- Member ID
- none on golden record
- Date of birth
- 1977-04-14
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-402002
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group N/A
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,362.65 of $2,500.0055%
- Out-of-pocket maximum
- $998.50 of $7,500.0013%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $53.00 | $32.86 | $32.86 | $0.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 2 | $53.00 | $32.86 | $32.86 | $0.00 | Paid |
| Totals | $106.00 | $65.72 | $65.72 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-142272
- 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-035093 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-06-02: MEDICARE-ADV-B (MA), effective 2024-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 14 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 Laboratories2026-06-02 13:26
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-06-02: MEDICARE-ADV-B (MA), effective 2024-09-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011820 | 2026-06-02 | Northgate Clinical Laboratories | $106.00 | Denied |
| CLM-2026-025323 | 2026-05-05 | Riverside Bone and Joint Center | $452.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.