CLM-2026-026533
Northgate Reference Lab, Clinical Laboratory. Service 2025-06-10 at independent laboratory (POS 81). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Lawrence Hoffman
- Member ID
- UHC-12016-65
- Date of birth
- 1971-02-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-430068
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3130
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,562.11 of $3,500.0073%
- Out-of-pocket maximum
- $2,939.79 of $10,500.0028%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2558563716
- Network
- In network
- Rendering NPI
- 2558563716
- Location
- Minneapolis, MN · TIN 36-3280776
- 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 | $45.00 | $27.90 | — | — | DeniedCO29 |
| 2 | 85025 | Complete blood count with differential | — | 1 | 1,2 | $35.00 | $21.70 | — | — | DeniedCO29 |
| Totals | $80.00 | $49.60 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-480221
- 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-001881 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-06-10: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Fail | CO29 | Received 210 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Reference Lab (2558563716). | |
| 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 Reference Lab2025-06-10 12:05
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-06 02:23
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 210 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026811 | 2026-08-16 | Desert Diagnostic Imaging | $592.00 | Approved |
| CLM-2026-022678 | 2026-07-20 | Riverside Regional Medical Center | $175.00 | Needs review |
| CLM-2026-033387 | 2026-08-06 | Cornerstone Orthopedic Specialists | $6,375.00 | 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
Received after the timely-filing limit.