CLM-2026-026528
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-06-05 at office (POS 11). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Katherine Dixon
- Member ID
- UHC-09672-15
- Date of birth
- 1989-07-28
- Identity
- Verified6 records, confidence 0.94
- Claim record
- CLMCLM-412983
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1423
- Coverage period
- 2024-09-01 to present
- Deductible
- $435.36 of $1,000.0044%
- Out-of-pocket maximum
- $413.39 of $2,000.0021%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2354462238
- Network
- In network
- Rendering NPI
- 7372036526
- Location
- Los Angeles, CA · TIN 17-5866014
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $332.00 | $205.84 | $20.00 | $185.84 | Paid |
| Totals | $332.00 | $205.84 | $20.00 | $185.84 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-963570
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007502 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-05: SELECT-EPO (EPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 42 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 (2354462238). | |
| 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 Associates2026-06-05 09:41
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003304 | 2026-08-08 | Riverside Orthopedic Specialists | $240.00 | Approved |
| CLM-2026-029185 | 2026-08-23 | Lakeside Dermatology Clinic | $296.00 | Approved |
| CLM-2026-002398 | 2026-07-19 | Evergreen Diagnostic Imaging | $2,274.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.