CLM-2026-030805
Northgate Medical Group, Family Medicine. Service 2026-07-19 at office (POS 11). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Kayla Richards
- Member ID
- UHC-42568-66
- Date of birth
- 1976-01-10
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-420026
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3851
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,877.38 of $2,500.0075%
- Out-of-pocket maximum
- $1,717.31 of $7,500.0023%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4702080423
- Network
- In network
- Rendering NPI
- 6284125807
- Location
- Charlotte, NC · TIN 83-7399373
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $150.00 | $93.00 | — | — | Review |
| Totals | $150.00 | $93.00 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-439559
- 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-009104 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-07-19: OPTIONS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 59 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-030804, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Medical Group (4702080423). | |
| 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 Group2026-07-19 14:20
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-09-16 03:27
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-16 15:02
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 engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-030804, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030804 | 2026-07-19 | Evergreen Family Practice | $150.00 | Approved |
| CLM-2026-030309 | 2026-03-19 | Riverside Digestive Health Center | $1,403.00 | Needs review |
| CLM-2026-030308 | 2026-03-19 | Sunrise Digestive Health Center | $1,403.00 | Approved |
| CLM-2026-005072 | 2025-12-21 | Lakeside Medical Group | $310.00 | 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.