CLM-2026-027500
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-04-15 at independent laboratory (POS 81). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Charlotte Kelyl
- Member ID
- UHC-07800-37
- Date of birth
- 1989-05-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413802
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0791
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,987.35 of $3,500.0057%
- Out-of-pocket maximum
- $1,191.36 of $14,000.009%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9874235952
- Network
- In network
- Rendering NPI
- 9874235952
- Location
- Charlotte, NC · TIN 55-1691702
- 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 | 85025 | Complete blood count with differential | 59 | 1 | 1 | $45.00 | $27.90 | — | — | Review |
| 2 | 87086 | Urine culture | 59 | 1 | 2 | $57.00 | $35.34 | — | — | Review |
| Totals | $102.00 | $63.24 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-915663
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030637 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: OPTIONS-PPO (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 29 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 Clinical Laboratories (9874235952). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Laboratories2026-04-15 16:40
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-05-14 03:55
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-14 17:22
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Medical recordrecords_PA-915663.pdf12 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Modifier 59 supported: distinct anatomical site documented.