CLM-2026-028650
Northgate Reference Lab, Clinical Laboratory. Service 2026-04-17 at independent laboratory (POS 81). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Debra Ortega
- Member ID
- UHC-53202-94
- Date of birth
- 1998-11-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418587
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9290
- Coverage period
- 2023-12-01 to present
- Deductible
- $898.25 of $1,000.0090%
- Out-of-pocket maximum
- $89.01 of $4,000.002%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $31.00 | $19.22 | $19.22 | $0.00 | Paid |
| 2 | 83036 | Hemoglobin A1c | — | 1 | 2 | $80.00 | $49.60 | $49.60 | $0.00 | Paid |
| 3 | 80061 | Lipid panel | — | 1 | 2 | $64.00 | $39.68 | $34.96 | $4.72 | Paid |
| Totals | $175.00 | $108.50 | $103.78 | $4.72 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-627715
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026252 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-17: SELECT-EPO (EPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 2 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 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 Lab2026-04-17 14:58
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028651 | 2026-04-17 | Northgate Reference Lab | $175.00 | Needs review |
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.