CLM-2026-022321
Northgate Medical Group, Internal Medicine. Service 2025-07-19 at office (POS 11). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Susan Coleman
- Member ID
- UHC-57625-86
- Date of birth
- 1952-10-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411637
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0741
- Coverage period
- 2025-03-01 to present
- Deductible
- $871.16 of $1,000.0087%
- Out-of-pocket maximum
- $382.92 of $2,000.0019%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 2464833716
- Location
- Dallas, TX · TIN 90-6599797
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $111.00 | $68.82 | — | — | DeniedCO29 |
| Totals | $111.00 | $68.82 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-591008
- 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-008105 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-07-19: CHOICE-PLUS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Fail | CO29 | Received 192 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (5749254103). | |
| 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 Group2025-07-19 12:10
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-01-27 06:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 192 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018423 | 2026-01-29 | Evergreen Primary Care Associates | $452.00 | Approved |
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
Received after the timely-filing limit.