Professional claim · CMS-1500 · EDI 837P
CLM-2026-016791
Northgate Medical Group, Internal Medicine. Service 2026-04-29 at office (POS 11). Received 2026-05-13.
Approved
Billed
$710.00
2 lines
Allowed
$440.20
contract rate applied
Plan pays
$415.20
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ann Sullivan
- Member ID
- UHC-58187-57
- Date of birth
- 1992-08-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407452
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7101
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,126.32 of $1,500.0075%
- Out-of-pocket maximum
- $138.61 of $3,000.005%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 5268059305
- Location
- Dallas, TX · TIN 90-6599797
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $308.00 | $190.96 | $25.00 | $165.96 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $402.00 | $249.24 | $0.00 | $249.24 | Paid |
| Totals | $710.00 | $440.20 | $25.00 | $415.20 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-148197
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-000819 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-29: SELECT-EPO (EPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 14 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Medical Group2026-04-29 11:36
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$710.00
Plan discount
$269.80
contracted rate
Plan paid
$415.20
You may owe
$25.00
copay, deductible and coinsurance
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-2026-013212 | 2026-06-20 | Lakeside Bone and Joint Center | $31,579.00 | Needs review |
| CLM-2026-000140 | 2025-11-24 | Cornerstone Digestive Health Center | $2,242.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.