CLM-2026-024489
Northgate Reference Lab, Clinical Laboratory. Service 2026-08-07 at independent laboratory (POS 81). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Fatima Espinoza
- Member ID
- UHC-85345-13
- Date of birth
- 1987-11-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-419339
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0425
- Coverage period
- 2021-09-01 to present
- Deductible
- $406.14 of $500.0081%
- Out-of-pocket maximum
- $367.35 of $2,000.0018%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2558563716
- Network
- In network
- Rendering NPI
- 2558563716
- Location
- Minneapolis, MN · TIN 36-3280776
- 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 | 80061 | Lipid panel | — | 1 | 1 | $74.00 | $45.88 | — | — | DeniedCO18 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $77.00 | $47.74 | — | — | DeniedCO18 |
| Totals | $151.00 | $93.62 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-438518
- 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-021476 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-07: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024488: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Reference Lab (2558563716). | |
| 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 Reference Lab2026-08-07 13:45
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-08-24 02:00
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-24 17:55
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-024488: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004559 | 2026-07-13 | Mesa Clinical Laboratories | $50.00 | Approved |
| CLM-2026-024488 | 2026-08-07 | Northgate Reference Lab | $151.00 | Approved |
| CLM-2026-024969 | 2025-10-11 | Meadow Family Practice | $281.00 | 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
Exact duplicate of an earlier submission.