Claims workbench/CLM-2026-025164

Professional claim · CMS-1500 · EDI 837P

CLM-2026-025164

Northgate Medical Group, Family Medicine. Service 2025-12-02 at office (POS 11). Received 2026-01-03.

Needs review

Billed

$495.00

2 lines

Allowed

$306.90

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Frank Castillo
Member ID: UHC-40282-62
Date of birth: 2005-01-02
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-411976
Relationship: Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-8031
Coverage period: 2022-03-01 to present
Deductible: $36.37 of $1,500.002%
Out-of-pocket maximum: $1,441.01 of $3,000.0048%
Copays: office $30.00, specialist $75.00, emergency $250.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 6636200761
Network: In network
Rendering NPI: 4439642107
Location: Mesa, AZ · TIN 30-3649363
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	99395	Preventive visit, 18-39 years	59	1	1	$292.00	$181.04	—	—	Review
2	99203	Office visit, new patient, low complexity	59	1	2	$203.00	$125.86	—	—	Review
Totals						$495.00	$306.90	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-570330
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-000753 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-02: NULL (PPO), effective 2022-03-01.
Timely filing	Pass		Received 32 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 (6636200761).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Medical Group2025-12-02 18:06
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-01-03 05:04
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Medical recordrecords_PA-570330.pdf6 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
AI recommendationDenied2026-10-21 14:05
The claim includes a preventive visit (99395) and an office visit (99203) with modifier 59, which are normally bundled services. The clinical note [N1] confirms that both procedures were performed at the same site during the same session as part of one service. Therefore, the use of modifier 59 is not justified, and the claim is denied for bundling (CO97).
AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · e0f5d219

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-021216	2026-02-18	Mesa Internal Medicine Associates	$359.00	Approved

AI recommendation

apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode

Deniedconfidence 0.95 Validated

CO97 Benefit included in another service already adjudicated

The claim includes a preventive visit (99395) and an office visit (99203) with modifier 59, which are normally bundled services. The clinical note [N1] confirms that both procedures were performed at the same site during the same session as part of one service. Therefore, the use of modifier 59 is not justified, and the claim is denied for bundling (CO97).

Evidence cited: [N1][L1][L2][R-ncci]

Latency

1,472 ms

Tokens

1,279 in / 156 out

Cost

$0.0015

Input hash dbe89b8eee64922d… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record it.

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Reason codes *

CO97 Benefit included in another service already adjudicated

Examiner rationale *

406 characters

ExaminerR. Patel (Claims Examiner II)

Will apply: deny

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity