CLM-2026-016104
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-02-23 at independent laboratory (POS 81). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Patrick Gardner
- Member ID
- UHC-61113-46
- Date of birth
- 2000-08-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415968
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2386
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,049.86 of $2,500.0082%
- Out-of-pocket maximum
- $3,267.60 of $7,500.0044%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9874235952
- Network
- In network
- Rendering NPI
- 9874235952
- Location
- Charlotte, NC · TIN 55-1691702
- 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 | $47.00 | $29.14 | $29.14 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | 25 | 1 | 1,2 | $50.00 | $31.00 | $31.00 | $0.00 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $75.00 | $46.50 | $46.50 | $0.00 | Paid |
| 4 | 80061 | Lipid panel | — | 1 | 2 | $73.00 | $45.26 | $45.26 | $0.00 | Paid |
| Totals | $245.00 | $151.90 | $151.90 | $0.00 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-608647
- 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-006446 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-23: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 27 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 (9874235952). | |
| 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 Laboratories2026-02-23 09:30
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001541 | 2026-01-06 | Heritage Medical Group | $458.00 | 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.