CLM-2026-023447
Northgate Medical Group, Family Medicine. Service 2026-04-16 at office (POS 11). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Elijah Hudsn
- Member ID
- UHC-86992-55
- Date of birth
- 1984-08-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-411506
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,450.33 of $3,500.0041%
- Out-of-pocket maximum
- $281.51 of $10,500.003%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4702080423
- Network
- In network
- Rendering NPI
- 1658362474
- Location
- Charlotte, NC · TIN 83-7399373
- 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 | 90471 | Immunization administration | — | 1 | 1 | $30.00 | $18.60 | — | — | Review |
| Totals | $30.00 | $18.60 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-242064
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026439 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-16: OPTIONS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 2 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 Medical Group (4702080423). | |
| 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 acute upper respiratory infection, unspecified. Plan discussed, medications ”. 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 Medical Group2026-04-16 11:13
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-18 01:36
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-18 16:57
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications ”.
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.