CLM-2026-025187
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-02-15 at independent laboratory (POS 81). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Heather Coleman
- Member ID
- UHC-89922-34
- Date of birth
- 1943-07-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-427414
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1241
- Coverage period
- 2021-11-01 to present
- Deductible
- $2,472.47 of $3,500.0071%
- Out-of-pocket maximum
- $1,366.46 of $7,000.0020%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 7617256269
- Network
- In network
- Rendering NPI
- 7617256269
- Location
- Denver, CO · TIN 27-8863034
- 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 | $59.00 | $36.58 | — | — | PendedIDQ |
| 2 | 87086 | Urine culture | — | 1 | 1 | $50.00 | $31.00 | — | — | PendedIDQ |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $46.00 | $28.52 | — | — | PendedIDQ |
| Totals | $155.00 | $96.10 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-541585
- 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 | Fail | IDQ | Member record is in open steward case CASE-002864; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-02-15: NULL (PPO), effective 2021-11-01. | |
| 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 Clinical Laboratories (7617256269). | |
| 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 Clinical Laboratories2026-02-15 17:18
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002864; payment withheld until the identity is confirmed.
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
Clean claim, priced at contract rate.