CLM-2026-030577
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-05-03 at office (POS 11). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Lauren Montgomery
- Member ID
- UHC-75031-08
- Date of birth
- 1983-02-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417048
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5686
- Coverage period
- 2025-11-01 to 2026-02-05
- Deductible
- $477.42 of $1,000.0048%
- Out-of-pocket maximum
- $1,010.27 of $4,000.0025%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9124785673
- Network
- In network
- Rendering NPI
- 1362774873
- Location
- Nashville, TN · TIN 42-1533753
- 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 | $228.00 | $141.36 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $76.00 | $47.12 | — | — | DeniedCO27 |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $81.00 | $50.22 | — | — | DeniedCO27 |
| Totals | $385.00 | $238.70 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
- Patient account
- PA-668305
- 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-005400 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-03 is after coverage terminated on 2026-02-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 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 (9124785673). | |
| 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 Associates2026-05-03 09:22
Patient seen for chronic kidney disease, stage 3 unspecified.
- SystemSystem: Claims system2026-06-09 04:17
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-09 14:37
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-03 is after coverage terminated on 2026-02-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025261 | 2026-06-27 | Summit Medical Group | $359.00 | Denied |
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.