CLM-2026-014867
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-02-19 at office (POS 11). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Judith Guzman
- Member ID
- UHC-84824-01
- Date of birth
- 1944-02-20
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-427523
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4728
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,699.55 of $3,500.0077%
- Out-of-pocket maximum
- $1,662.34 of $7,000.0024%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2354462238
- Network
- In network
- Rendering NPI
- 6456173148
- Location
- Los Angeles, CA · TIN 17-5866014
- Authorisation / referral
- none / REF241990
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 | $72.00 | $44.64 | $25.00 | $19.64 | Paid |
| Totals | $72.00 | $44.64 | $25.00 | $19.64 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-962372
- 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-024024 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-19: CORE-HMO (HMO), effective 2021-08-01. | |
| Timely filing | Pass | Received 44 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 (2354462238). | |
| 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 Associates2026-02-19 09:45
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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.