CLM-2026-012587
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-04-02 at office (POS 11). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Bobby Silva
- Member ID
- UHC-38822-20
- Date of birth
- 1966-06-25
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-400116
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8051
- Coverage period
- 2025-01-01 to 2026-06-27
- Deductible
- $402.40 of $3,500.0011%
- Out-of-pocket maximum
- $2,687.24 of $7,000.0038%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9124785673
- Network
- In network
- Rendering NPI
- 5192968902
- Location
- Nashville, TN · TIN 42-1533753
- Authorisation / referral
- none / REF791479
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO18 |
| Totals | $63.00 | $39.06 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-604647
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009233 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-02: NAVIGATE-HMO (HMO), effective 2025-01-01, terms 2026-06-27. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012586: 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 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 Associates2026-04-02 18:39
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-14 04:27
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-14 13:55
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-012586: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012586 | 2026-04-02 | Northgate Internal Medicine Associates | $63.00 | Approved |
| CLM-2026-030013 | 2026-01-28 | Northgate Heart Institute | $5,715.00 | 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.