CLM-2026-022729
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-05-11 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Omar Harvey
- Member ID
- UHC-08537-63
- Date of birth
- 2008-10-05
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424654
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3269
- Coverage period
- 2024-02-01 to present
- Deductible
- $752.76 of $3,500.0022%
- Out-of-pocket maximum
- $4,141.03 of $14,000.0030%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 9123519974
- Location
- Charlotte, NC · TIN 84-6447646
- Authorisation / referral
- none / REF238564
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 | $343.00 | $212.66 | — | — | Review |
| 2 | 93000 | Electrocardiogram with interpretation | 25 | 1 | 1 | $99.00 | $61.38 | — | — | Review |
| Totals | $442.00 | $274.04 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-612399
- 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-025114 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-11: CORE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 12 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 (1858506821). | |
| 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: “Patient seen for essential (primary) hypertension. Note dictated; signature pending.”. 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 Associates2026-05-11 11:08
Patient seen for essential (primary) hypertension. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-23 03:31
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-23 09:14
Called the provider office; awaiting documentation.
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: “Patient seen for essential (primary) hypertension. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009169 | 2026-10-06 | Canyon Reference Lab | $108.00 | Denied |
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.