Professional claim · CMS-1500 · EDI 837P
CLM-2026-028684
Northgate Medical Group, Internal Medicine. Service 2026-02-08 at office (POS 11). Received 2026-03-01.
Needs review
Billed
$648.00
2 lines
Allowed
$401.76
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Review
CO97
Decided by
Nobody yet
open
Member
Resolved through the identity graph
- Member
- Santos Grace
- Member ID
- UHC-38799-01
- Date of birth
- 1972-06-27
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-430836
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8804
- Coverage period
- 2022-10-01 to 2026-02-08
- Deductible
- $80.48 of $1,500.005%
- Out-of-pocket maximum
- $976.46 of $4,500.0022%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 4293130140
- Location
- Dallas, TX · TIN 90-6599797
- 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 | 99215 | Office visit, established patient, high complexity | 59 | 1 | 1 | $385.00 | $238.70 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $263.00 | $163.06 | — | — | Review |
| Totals | $648.00 | $401.76 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-608513
- 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-002834 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-02-08: OPTIONS-PPO (PPO), effective 2022-10-01, terms 2026-02-08. | |
| Timely filing | Pass | Received 21 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) | 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Medical Group2026-02-08 14:12
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-03-01 03:03
Attachments
Documents received with the claim
No attachments.
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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.