CLM-2026-017457
Northgate Medical Group, Internal Medicine. Service 2026-05-18 at office (POS 11). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Keith Ortiz
- Member ID
- UHC-75701-22
- Date of birth
- 1947-05-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416553
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2137
- Coverage period
- 2023-09-01 to present
- Deductible
- $1,752.99 of $2,500.0070%
- Out-of-pocket maximum
- $2,070.11 of $5,000.0041%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 5880738120
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $71.00 | $44.02 | — | — | DeniedCO18 |
| Totals | $71.00 | $44.02 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-288168
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008520 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-18: OPTIONS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-017456: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Group2026-05-18 14:27
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-08 00:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-017456: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017871 | 2026-09-08 | Valley Reference Lab | $134.00 | Approved |
| CLM-2026-017456 | 2026-05-18 | Northgate Medical Group | $71.00 | Approved |
| CLM-2026-015852 | 2026-02-17 | Meadow Physical Therapy | $324.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.