CLM-2026-025429
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-08-31 to 2026-09-01 at inpatient hospital (POS 21). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Jordan Wheeler
- Member ID
- UHC-10993-15
- Date of birth
- 1954-09-25
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-412252
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0169
- Coverage period
- 2023-11-01 to 2026-02-08
- Deductible
- $2,001.95 of $2,500.0080%
- Out-of-pocket maximum
- $3,662.96 of $10,000.0037%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9124785673
- Network
- In network
- Rendering NPI
- 4033609148
- Location
- Nashville, TN · TIN 42-1533753
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $214.00 | $117.70 | — | — | DeniedCO27 |
| Totals | $214.00 | $117.70 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-860611
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-31 to 2026-09-02
- 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-012816 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-31 is after coverage terminated on 2026-02-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 Internal Medicine Associates (9124785673). | |
| 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 Internal Medicine Associates2026-09-01 10:24
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-10-04 06:28
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-04 11:12
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-860611.pdf8 pages
Itemised statement totalling $214.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-31 is after coverage terminated on 2026-02-08.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017142 | 2026-08-13 | Unity Primary Care Associates | $511.00 | 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.