CLM-2026-028263
Northgate Medical Group, Family Medicine. Service 2025-12-18 at office (POS 11). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Nicole Richardson
- Member ID
- UHC-06257-82
- Date of birth
- 2008-09-22
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410811
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4475
- Coverage period
- 2021-06-01 to present
- Deductible
- $146.96 of $500.0029%
- Out-of-pocket maximum
- $800.71 of $2,000.0040%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3539927137
- Network
- In network
- Rendering NPI
- 5549202435
- Location
- Scottsdale, AZ · TIN 91-2030165
- 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 | 36415 | Venipuncture | — | 1 | 1 | $17.00 | $10.54 | $10.54 | $0.00 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $29.00 | $17.98 | $0.00 | $17.98 | Paid |
| Totals | $46.00 | $28.52 | $10.54 | $17.98 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-246844
- 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-001810 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-18: MEDICARE-ADV-A (MA), effective 2021-06-01. | |
| Timely filing | Pass | Received 19 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 (3539927137). | |
| 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 Group2025-12-18 14:26
Patient seen for type 2 diabetes mellitus without complications.
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-2026-007114 | 2026-06-27 | Mesa GI Associates | $2,207.00 | Approved |
| CLM-2026-011555 | 2026-04-05 | Harbor Family Practice | $530.00 | Needs review |
| CLM-2026-011554 | 2026-04-05 | Harbor Family Practice | $530.00 | Approved |
| CLM-2026-002622 | 2025-12-14 | Desert Clinical Laboratories | $112.00 | 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.