CLM-2026-017468
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-08-09 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Russell Andrews
- Member ID
- UHC-37663-59
- Date of birth
- 1989-04-11
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411170
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4985
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,709.66 of $3,500.0049%
- Out-of-pocket maximum
- $2,135.02 of $10,500.0020%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 3993817949
- Location
- Charlotte, NC · TIN 84-6447646
- Authorisation / referral
- none / REF455346
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 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $299.00 | $185.38 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $254.00 | $157.48 | — | — | Review |
| Totals | $553.00 | $342.86 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-457328
- 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-040265 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-09: CORE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 6 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 Internal Medicine Associates (1858506821). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Internal Medicine Associates2026-08-09 18:45
Patient seen for essential (primary) hypertension. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-08-15 02:52
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-15 17:57
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-457328.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009123 | 2026-06-22 | Canyon Internal Medicine Associates | $643.00 | Needs review |
| CLM-2026-009122 | 2026-06-22 | Canyon Internal Medicine Associates | $643.00 | 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
Bundled code pair; modifier 59 not supported by the operative note.