CLM-2026-015339
Northgate Medical Group, Internal Medicine. Service 2026-07-04 to 2026-07-07 at inpatient hospital (POS 21). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Christine Sims
- Member ID
- UHC-77833-63
- Date of birth
- 1992-06-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432591
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9522
- Coverage period
- 2025-04-01 to present
- Deductible
- $2,012.17 of $3,500.0057%
- Out-of-pocket maximum
- $889.91 of $7,000.0013%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 7377681193
- Location
- Dallas, TX · TIN 90-6599797
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $232.00 | $127.60 | $127.60 | $0.00 | Paid |
| Totals | $232.00 | $127.60 | $127.60 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-581013
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-04 to 2026-07-06
- 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-009588 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-04: OPTIONS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 41 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 Medical Group (5749254103). | |
| 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 Medical Group2026-07-07 12:56
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-581013.pdf6 pages
Itemised statement totalling $232.00 across 1 line.
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-2026-027822 | 2026-01-29 | Heritage Primary Care Associates | $15.00 | 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.