CLM-2026-027135
Northgate Medical Group, Internal Medicine. Service 2026-04-13 to 2026-04-16 at inpatient hospital (POS 21). Received 2026-04-15.
Member
Resolved through the identity graph
- Member
- Rachel Pirce
- Member ID
- UHC-44054-68
- Date of birth
- 1954-08-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404525
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3939
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,574.05 of $2,500.0063%
- Out-of-pocket maximum
- $990.46 of $10,000.0010%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 9012777774
- Location
- Dallas, TX · TIN 90-6599797
- Authorisation / referral
- none / REF196618
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 | $207.00 | $113.85 | — | — | PendedIDQ |
| Totals | $207.00 | $113.85 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-177361
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-13 to 2026-04-14
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002025; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-13: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received -1 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 Medical Group (5749254103). | |
| 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 Medical Group2026-04-16 16:10
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-177361.pdf9 pages
Itemised statement totalling $207.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002025; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Clean claim, priced at contract rate.