CLM-2026-024444
Northgate Medical Group, Family Medicine. Service 2026-06-18 at office (POS 11). Received 2026-06-21.
Member
Resolved through the identity graph
- Member
- Lauren Sandoval
- Member ID
- UHC-88391-59
- Date of birth
- 1955-08-17
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-423450
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4371
- Coverage period
- 2024-05-01 to 2026-03-08
- Deductible
- $148.50 of $1,000.0015%
- Out-of-pocket maximum
- $986.92 of $2,000.0049%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4702080423
- Network
- In network
- Rendering NPI
- 9198504604
- 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 | 36415 | Venipuncture | — | 1 | 1 | $12.00 | $7.44 | — | — | DeniedCO27 |
| Totals | $12.00 | $7.44 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-150905
- 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-005587 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-18 is after coverage terminated on 2026-03-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 | 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 Group2026-06-18 09:39
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-21 05:40
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-18 is after coverage terminated on 2026-03-08.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022465 | 2026-09-16 | Riverside Regional Medical Center | $230.00 | Denied |
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
Service after coverage termination.