CLM-2026-018164
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-02-06 at office (POS 11). Received 2026-02-27.
Member
Resolved through the identity graph
- Member
- Thomas Espinoza
- Member ID
- UHC-83698-81
- Date of birth
- 1980-07-04
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-408077
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-9077
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,215.86 of $1,500.0081%
- Out-of-pocket maximum
- $851.90 of $3,000.0028%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5634350545
- Network
- In network
- Rendering NPI
- 1089750602
- Location
- San Diego, CA · TIN 74-0606761
- 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 | $250.00 | $155.00 | $30.00 | $125.00 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | 25 | 1 | 1 | $46.00 | $28.52 | $0.00 | $28.52 | Paid |
| Totals | $296.00 | $183.52 | $30.00 | $153.52 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-125797
- 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-014226 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-06: UNKNOWN (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 21 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 (5634350545). | |
| 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 Internal Medicine Associates2026-02-06 12:07
Patient seen for type 2 diabetes mellitus with hyperglycemia.
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-2026-012462 | 2026-09-12 | Canyon Diagnostic Imaging | $312.00 | 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.