Professional claim · CMS-1500 · EDI 837P
CLM-2026-026691
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-09-03 at office (POS 11). Received 2026-10-18.
Approved
Billed
$392.00
2 lines
Allowed
$243.04
contract rate applied
Plan pays
$223.04
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Gabriel Sanders
- Member ID
- UHC-13138-62
- Date of birth
- 2006-05-23
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-428758
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6557
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,957.51 of $3,500.0056%
- Out-of-pocket maximum
- $180.87 of $14,000.001%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5325375595
- Network
- In network
- Rendering NPI
- 2604319741
- Location
- San Diego, CA · TIN 58-7197323
- Authorisation / referral
- none / REF710790
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $296.00 | $183.52 | $20.00 | $163.52 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 1,2 | $96.00 | $59.52 | $0.00 | $59.52 | Paid |
| Totals | $392.00 | $243.04 | $20.00 | $223.04 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-997693
- 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-013214 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-03: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 45 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 (5325375595). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Internal Medicine Associates2026-09-03 15:34
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$392.00
Plan discount
$148.96
contracted rate
Plan paid
$223.04
You may owe
$20.00
copay, deductible and coinsurance
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-2026-018689 | 2026-09-06 | Mesa Internal Medicine Associates | $2,621.00 | Needs review |
| CLM-2026-007717 | 2026-05-02 | Evergreen Family Practice | $263.00 | Approved |
| CLM-2026-023827 | 2026-01-10 | Desert Medical Group | $298.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.