CLM-2026-020148
Northgate Medical Group, Family Medicine. Service 2026-01-05 at office (POS 11). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Diane Sims
- Member ID
- UHC-36638-27
- Date of birth
- 1961-03-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414489
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5125
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,278.35 of $3,500.0065%
- Out-of-pocket maximum
- $5,741.23 of $14,000.0041%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4702080423
- Network
- In network
- Rendering NPI
- 2189697701
- Location
- Charlotte, NC · TIN 83-7399373
- 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 | $204.00 | $126.48 | $25.00 | $101.48 | Paid |
| Totals | $204.00 | $126.48 | $25.00 | $101.48 | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-575913
- 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-006217 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-05: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 15 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 Medical Group (4702080423). | |
| 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 Medical Group2026-01-05 11:34
Patient seen for acute upper respiratory infection, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-20 00:34
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-575913.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
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
Authorisation must be confirmed with UM before payment.