CLM-2026-018914
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-07-02 at office (POS 11). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Raymond McDonald
- Member ID
- UHC-43422-68
- Date of birth
- 1946-09-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431359
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8799
- Coverage period
- 2022-11-01 to present
- Deductible
- $834.18 of $1,000.0083%
- Out-of-pocket maximum
- $943.81 of $3,000.0031%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5634350545
- Network
- In network
- Rendering NPI
- 8059553502
- 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 | 59 | 1 | 1 | $273.00 | $169.26 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $319.00 | $197.78 | — | — | Review |
| Totals | $592.00 | $367.04 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. J44.9 COPD, unspecified
- Patient account
- PA-385529
- 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-017158 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-02: MEDICARE-ADV-A (MA), effective 2022-11-01. | |
| Timely filing | Pass | Received 36 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) | 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 Associates2026-07-02 12:14
Patient seen for chronic kidney disease, stage 3 unspecified. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-08-07 03:32
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-385529.pdf12 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
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.