CLM-2026-015210
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-01-08 at independent laboratory (POS 81). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Patrick Perez
- Member ID
- UHC-74189-68
- Date of birth
- 1975-05-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413069
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group -
- Coverage period
- 2025-09-01 to present
- Deductible
- $1,383.47 of $2,500.0055%
- Out-of-pocket maximum
- $1,787.04 of $5,000.0036%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9320502187
- Network
- In network
- Rendering NPI
- 9320502187
- Location
- Miami, FL · TIN 99-9648979
- 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 | $69.00 | $42.78 | — | — | Review |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $64.00 | $39.68 | — | — | Review |
| Totals | $133.00 | $82.46 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-255487
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010822 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-08: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 29 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 (9320502187). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Clinical Laboratories2026-01-08 12:41
Patient seen for urinary tract infection, site not specified. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-06 00:00
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-06 10:29
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001454 | 2026-05-10 | Evergreen Primary Care Associates | $524.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.