CLM-2026-020409
Northgate Reference Lab, Clinical Laboratory. Service 2026-05-17 at independent laboratory (POS 81). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Sara Berry
- Member ID
- UHC-72712-60
- Date of birth
- 1946-03-16
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-404937
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7729
- Coverage period
- 2023-08-01 to 2026-02-11
- Deductible
- $680.65 of $1,000.0068%
- Out-of-pocket maximum
- $1,176.00 of $3,000.0039%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2558563716
- Network
- In network
- Rendering NPI
- 2558563716
- Location
- Minneapolis, MN · TIN 36-3280776
- Authorisation / referral
- none / REF165922
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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $80.00 | $49.60 | — | — | DeniedCO27 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $38.00 | $23.56 | — | — | DeniedCO27 |
| Totals | $118.00 | $73.16 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- Patient account
- PA-322865
- 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-032162 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-17 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 41 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 (2558563716). | |
| 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 Lab2026-05-17 15:17
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-27 02:45
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 2026-05-17 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
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.