CLM-2026-021890
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-01-16 at office (POS 11). Received 2026-02-20.
Member
Resolved through the identity graph
- Member
- Natalie Morgan
- Member ID
- UHC-34630-48
- Date of birth
- 1955-12-16
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-427826
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4637
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,145.74 of $1,500.0076%
- Out-of-pocket maximum
- $217.17 of $4,500.005%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5325375595
- Network
- In network
- Rendering NPI
- 9131327659
- Location
- San Diego, CA · TIN 58-7197323
- 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 | $391.00 | $242.42 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $79.00 | $48.98 | — | — | Review |
| Totals | $470.00 | $291.40 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-822585
- 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-014686 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-16: MEDICARE-ADV-B (MA), effective 2024-02-01. | |
| Timely filing | Pass | Received 35 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 (5325375595). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications rec”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Internal Medicine Associates2026-01-16 17:30
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-20 03:24
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-20 09:35
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications rec”.
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
Development letter outstanding.