CLM-2026-014789
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-06-29 at independent laboratory (POS 81). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Kim Owens
- Member ID
- UHC-15681-21
- Date of birth
- 1954-05-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414475
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3649
- Coverage period
- 2022-07-01 to present
- Deductible
- $358.65 of $500.0072%
- Out-of-pocket maximum
- $194.94 of $1,000.0019%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 1 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $42.00 | $26.04 | $26.04 | $0.00 | Paid |
| 2 | 87086 | Urine culture | — | 1 | 1 | $68.00 | $42.16 | $42.16 | $0.00 | Paid |
| 3 | 80061 | Lipid panel | — | 1 | 1 | $60.00 | $37.20 | $37.20 | $0.00 | Paid |
| Totals | $170.00 | $105.40 | $105.40 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-825482
- 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-012065 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: NULL (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 26 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 (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 Laboratories2026-06-29 17:53
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 12:44Clean claim.
Other claims for this member
Same resolved identity
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.