CLM-2026-012246
Northgate Internal Medicine Associates, Internal Medicine. Service 2025-12-20 at office (POS 11). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Jacqueline Jimenez
- Member ID
- UHC-16993-83
- Date of birth
- 1950-09-07
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-404309
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5339
- Coverage period
- 2021-12-01 to present
- Deductible
- $834.51 of $1,000.0083%
- Out-of-pocket maximum
- $842.12 of $2,000.0042%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9124785673
- Network
- In network
- Rendering NPI
- 2950861403
- Location
- Nashville, TN · TIN 42-1533753
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $210.00 | $130.20 | $20.00 | $110.20 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $287.00 | $177.94 | $0.00 | $177.94 | Paid |
| Totals | $497.00 | $308.14 | $20.00 | $288.14 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-297011
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002393 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-20: N/A (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 36 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 (9124785673). | |
| 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 Associates2025-12-20 09:49
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022643 | 2026-10-04 | Meadow Primary Care Associates | $506.00 | 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.