CLM-2026-020636
Northgate Internal Medicine Associates, Internal Medicine. Service 2025-12-15 at office (POS 11). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Alexis Murray
- Member ID
- UHC-07375-77
- Date of birth
- 1990-12-15
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-431102
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2172
- Coverage period
- 2025-04-01 to present
- Deductible
- $438.93 of $2,500.0018%
- Out-of-pocket maximum
- $677.82 of $5,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9124785673
- Network
- In network
- Rendering NPI
- 2778768509
- Location
- Nashville, TN · TIN 42-1533753
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $366.00 | $226.92 | $40.00 | $186.92 | Paid |
| Totals | $366.00 | $226.92 | $40.00 | $186.92 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-556233
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005291 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-15: N/A (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 33 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 (9124785673). | |
| 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 Internal Medicine Associates2025-12-15 11:23
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-17 02:33
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-556233.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 engineApproved2026-10-21 13:43Clean 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.