CLM-2026-030305
Northgate Medical Group, Family Medicine. Service 2026-08-22 at office (POS 11). Received 2026-09-20.
Member
Resolved through the identity graph
- Member
- Carolyn Wright
- Member ID
- UHC-94808-34
- Date of birth
- 1976-05-19
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-432619
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1214
- Coverage period
- 2022-10-01 to present
- Deductible
- $217.14 of $500.0043%
- Out-of-pocket maximum
- $271.43 of $2,000.0014%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6636200761
- Network
- In network
- Rendering NPI
- 9828505583
- Location
- Mesa, AZ · TIN 30-3649363
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $204.00 | $126.48 | — | — | Review |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $15.00 | $9.30 | — | — | Review |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $35.00 | $21.70 | — | — | Review |
| Totals | $254.00 | $157.48 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-463574
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021862 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-22: MEDICARE-ADV-A (MA), effective 2022-10-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-030304, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Medical Group (6636200761). | |
| 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 Group2026-08-22 12:49
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-09-20 04:25
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-20 11:46
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-030304, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030304 | 2026-08-22 | Heritage Family Practice | $254.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.