CLM-2026-018723
Northgate Reference Lab, Clinical Laboratory. Service 2026-03-26 at independent laboratory (POS 81). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Jessica Adams
- Member ID
- UHC-97802-47
- Date of birth
- 1961-07-22
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-418596
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6200
- Coverage period
- 2021-06-01 to 2026-02-06
- Deductible
- $1,729.68 of $2,500.0069%
- Out-of-pocket maximum
- $816.54 of $10,000.008%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7207177792
- Network
- In network
- Rendering NPI
- 7207177792
- Location
- Miami, FL · TIN 47-3638402
- 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 | $41.00 | $25.42 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | — | 1 | 1 | $70.00 | $43.40 | — | — | DeniedCO27 |
| 3 | 83036 | Hemoglobin A1c | — | 1 | 2 | $53.00 | $32.86 | — | — | DeniedCO27 |
| Totals | $164.00 | $101.68 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-408452
- 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-009046 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-26 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 19 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 Reference Lab (7207177792). | |
| 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 Reference Lab2026-03-26 16:51
Follow-up for urinary tract infection, site not specified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-14 01:28
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-26 is after coverage terminated on 2026-02-06.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022404 | 2026-06-29 | Harbor Cardiovascular Associates | $671.00 | Denied |
| CLM-2026-005799 | 2026-03-27 | Northgate Orthopedic Specialists | $37,463.00 | Denied |
| CLM-2026-007161 | 2026-02-28 | Meadow Primary Care Associates | $362.00 | Denied |
| CLM-2026-025279 | 2026-01-19 | Desert Internal Medicine Associates | $259.00 | Needs review |
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
Service after coverage termination.