CLM-2026-028843
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-03-03 at office (POS 11). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Kelly Nunez
- Member ID
- UHC-71535-19
- Date of birth
- 1969-07-08
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407525
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2423
- Coverage period
- 2021-09-01 to present
- Deductible
- $27.99 of $500.006%
- Out-of-pocket maximum
- $403.05 of $2,000.0020%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1858506821
- Network
- In network
- Rendering NPI
- 6179862589
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $237.00 | $146.94 | $20.00 | $126.94 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $333.00 | $206.46 | $0.00 | $206.46 | Paid |
| Totals | $570.00 | $353.40 | $20.00 | $333.40 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. J44.9 COPD, unspecified
- Patient account
- PA-469990
- 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-017731 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-03: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| 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 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 Associates2026-03-03 13:15
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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-2026-003549 | 2026-06-26 | Heritage Physical Therapy | $489.00 | 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.