Professional claim · CMS-1500 · EDI 837P
CLM-2026-030940
Northgate Medical Group, Family Medicine. Service 2025-12-24 at office (POS 11). Received 2026-01-26.
Approved
Billed
$177.00
1 line
Allowed
$109.74
contract rate applied
Plan pays
$89.74
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Marc Sullivan
- Member ID
- UHC-87623-30
- Date of birth
- 1979-10-28
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-426998
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8622
- Coverage period
- 2025-05-01 to present
- Deductible
- $832.34 of $1,500.0055%
- Out-of-pocket maximum
- $1,403.04 of $6,000.0023%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4702080423
- Network
- In network
- Rendering NPI
- 5441263840
- 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 | $177.00 | $109.74 | $20.00 | $89.74 | Paid |
| Totals | $177.00 | $109.74 | $20.00 | $89.74 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-932567
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007751 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-24: SELECT-EPO (EPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 33 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 (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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Medical Group2025-12-24 16:36
Patient seen for hyperlipidemia, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$177.00
Plan discount
$67.26
contracted rate
Plan paid
$89.74
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030941 | 2025-12-24 | Northgate Medical Group | $177.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.