Professional claim · CMS-1500 · EDI 837P
CLM-2026-031445
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-06-28 at office (POS 11). Received 2026-08-04.
Denied
Billed
$456.00
2 lines
Allowed
$282.72
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Ryan Hill
- Member ID
- UHC-00515-59
- Date of birth
- 1997-08-08
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-423633
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5680
- Coverage period
- 2024-08-01 to 2026-04-17
- Deductible
- $2,301.72 of $3,500.0066%
- Out-of-pocket maximum
- $336.63 of $10,500.003%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5325375595
- Network
- In network
- Rendering NPI
- 4002628756
- Location
- San Diego, CA · TIN 58-7197323
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $397.00 | $246.14 | — | — | DeniedCO27 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $59.00 | $36.58 | — | — | DeniedCO27 |
| Totals | $456.00 | $282.72 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-220537
- 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-024307 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-28 is after coverage terminated on 2026-04-17. 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 (5325375595). | |
| 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. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Internal Medicine Associates2026-06-28 13:41
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-04 02:31
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-28 is after coverage terminated on 2026-04-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023706 | 2026-03-09 | Desert Internal Medicine Associates | $276.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.