CLM-2026-012154
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-07-11 at office (POS 11). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Denise Richardson
- Member ID
- UHC-40221-43
- Date of birth
- 2002-10-07
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-415068
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-2041
- Coverage period
- 2021-01-01 to present
- Deductible
- $2,100.79 of $2,500.0084%
- Out-of-pocket maximum
- $854.40 of $5,000.0017%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5325375595
- Network
- In network
- Rendering NPI
- 8016901158
- Location
- San Diego, CA · TIN 58-7197323
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $390.00 | $241.80 | $20.00 | $221.80 | Paid |
| Totals | $390.00 | $241.80 | $20.00 | $221.80 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-482291
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013365 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-11: - (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 2 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 (5325375595). | |
| 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 Internal Medicine Associates2026-07-11 10:47
Patient seen for chronic kidney disease, stage 3 unspecified.
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 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033376 | 2026-06-15 | Canyon Community Hospital | $463.00 | Approved |
| CLM-2026-004400 | 2026-02-09 | Riverside Primary Care Associates | $261.00 | Approved |
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.