CLM-2026-028738
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-06-17 at office (POS 11). Received 2026-08-01.
Member
Resolved through the identity graph
- Member
- Mariana Cook
- Member ID
- UHC-98819-75
- Date of birth
- 1996-12-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431240
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8253
- Coverage period
- 2022-11-01 to 2026-04-02
- Deductible
- $342.67 of $1,000.0034%
- Out-of-pocket maximum
- $346.06 of $2,000.0017%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 3505180372
- Location
- Charlotte, NC · TIN 84-6447646
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $48.00 | $29.76 | — | — | DeniedCO27 |
| Totals | $48.00 | $29.76 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-136415
- 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-024040 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-17 is after coverage terminated on 2026-04-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 Internal Medicine Associates (1858506821). | |
| 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 Internal Medicine Associates2026-06-17 17:09
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-08-01 00:04
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-01 15:24
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-17 is after coverage terminated on 2026-04-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015712 | 2026-02-26 | Canyon Community Hospital | $1,039.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.