CLM-2026-025496
Northgate Clinical Laboratories, Clinical Laboratory. Service 2025-12-19 at independent laboratory (POS 81). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Ronald Valdez
- Member ID
- UHC-61056-55
- Date of birth
- 1978-10-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424698
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9381
- Coverage period
- 2025-12-01 to present
- Deductible
- $379.86 of $500.0076%
- Out-of-pocket maximum
- $98.22 of $1,500.007%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9320502187
- Network
- In network
- Rendering NPI
- 9320502187
- Location
- Miami, FL · TIN 99-9648979
- 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 | 83036 | Hemoglobin A1c | — | 1 | 1 | $55.00 | $34.10 | — | — | Review |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1 | $53.00 | $32.86 | — | — | Review |
| Totals | $108.00 | $66.96 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-233263
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000685 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-19: SELECT-EPO (EPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-025495; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Clinical Laboratories (9320502187). | |
| 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 Laboratories2025-12-19 18:22
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-09 01:16
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-09 10:49
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-025495.pdf1 page
Provider cover letter requesting replacement of CLM-2026-025495.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-025495; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-21 14:15This is a replacement claim (frequency code 7) for an earlier claim that was approved. The provider has corrected an error in the original claim, specifically the units on line 2. The member is eligible, the provider is in-network, and the claim is within the timely filing limit. The clinical note supports the medical necessity of the services. The original claim must be voided when this replacement claim is adjudicated.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 64344c33
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025495 | 2025-12-19 | Northgate Clinical Laboratories | $108.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim (frequency code 7) for an earlier claim that was approved. The provider has corrected an error in the original claim, specifically the units on line 2. The member is eligible, the provider is in-network, and the claim is within the timely filing limit. The clinical note supports the medical necessity of the services. The original claim must be voided when this replacement claim is adjudicated.
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
Replacement claim supersedes the original.