CLM-2026-030323
Northgate Medical Group, Internal Medicine. Service 2026-06-19 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- David Hansen
- Member ID
- UHC-62023-76
- Date of birth
- 2004-02-20
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-412269
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7286
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,396.91 of $2,500.0056%
- Out-of-pocket maximum
- $3,286.10 of $10,000.0033%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 4343528988
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $208.00 | $128.96 | — | — | Review |
| Totals | $208.00 | $128.96 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-338737
- 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-022426 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-19: CHOICE-PLUS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 18 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) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for copd, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Medical Group2026-06-19 17:42
Patient seen for copd, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-07 06:50
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-07 14:40
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for copd, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020252 | 2026-05-17 | Riverside Bone and Joint Center | $265.00 | Approved |
| CLM-2026-011649 | 2025-10-09 | Riverside Community Hospital | $956.00 | Denied |
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
Development letter outstanding.