CLM-2026-030681
Northgate Reference Lab, Clinical Laboratory. Service 2026-01-03 at independent laboratory (POS 81). Received 2026-01-29.
Member
Resolved through the identity graph
- Member
- Ann Ferguson
- Member ID
- UHC-46867-34
- Date of birth
- 1972-06-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424629
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9786
- Coverage period
- 2024-08-01 to present
- Deductible
- $525.05 of $1,000.0053%
- Out-of-pocket maximum
- $1,193.29 of $4,000.0030%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 2558563716
- Network
- In network
- Rendering NPI
- 2558563716
- Location
- Minneapolis, MN · TIN 36-3280776
- 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 | $41.00 | $25.42 | — | — | Review |
| Totals | $41.00 | $25.42 | — | — | ||||||
- 1. N39.0 Urinary tract infection, site not specifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-821450
- 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-008555 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-03: NULL (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 26 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 Reference Lab (2558563716). | |
| 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 urinary tract infection, site not specified. Note dictated; signature pen”. 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 Reference Lab2026-01-03 16:12
Patient seen for urinary tract infection, site not specified. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-29 06:56
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for urinary tract infection, site not specified. Note dictated; signature pen”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027713 | 2026-08-25 | Canyon Clinical Laboratories | $42.00 | Approved |
| CLM-2026-003479 | 2026-02-21 | Desert Medical Group | $566.00 | 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
Development letter outstanding.