Professional claim · CMS-1500 · EDI 837P
CLM-2026-019966
Northgate Primary Care Associates, Family Medicine. Service 2026-04-13 at office (POS 11). Received 2026-05-27.
DeniedOut of network
Billed
$270.00
2 lines
Allowed
$121.50
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Angela Bailey
- Member ID
- UHC-80041-28
- Date of birth
- 1948-09-23
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-416081
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9632
- Coverage period
- 2023-11-01 to 2026-04-03
- Deductible
- $37.20 of $1,000.004%
- Out-of-pocket maximum
- $1,060.12 of $3,000.0035%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4637508332
- Network
- Out of network
- Rendering NPI
- 6689880758
- Location
- Minneapolis, MN · TIN 67-8207814
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $253.00 | $113.85 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $17.00 | $7.65 | — | — | DeniedCO27 |
| Totals | $270.00 | $121.50 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. I10 Essential (primary) hypertension
Claim header
- Patient account
- PA-229893
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028689 (verified, link confidence 0.98). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-13 is after coverage terminated on 2026-04-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 | Fail | CO204 | Billing provider 4637508332 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Primary Care Associates2026-04-13 14:40
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-05-27 02:02
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-13 is after coverage terminated on 2026-04-03. Provider network: Billing provider 4637508332 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014600 | 2026-09-05 | Summit Endocrine Associates | $355.00 | Denied |
| CLM-2026-013528 | 2026-05-12 | Mesa Dermatology Clinic | $782.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.