CLM-2026-031572
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-04-28 at office (POS 11). Received 2026-06-03.
Member
Resolved through the identity graph
- Member
- Christian Edwards
- Member ID
- UHC-82513-35
- Date of birth
- 1977-03-19
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416043
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9815
- Coverage period
- 2025-02-01 to present
- Deductible
- $1,985.32 of $2,500.0079%
- Out-of-pocket maximum
- $2,763.74 of $7,500.0037%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 2354462238
- Network
- In network
- Rendering NPI
- 1713946485
- Location
- Los Angeles, CA · TIN 17-5866014
- Authorisation / referral
- none / REF422885
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 | $285.00 | $176.70 | $20.00 | $156.70 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $94.00 | $58.28 | $0.00 | $58.28 | Paid |
| Totals | $379.00 | $234.98 | $20.00 | $214.98 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-467374
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025587 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-28: CORE-HMO (HMO), effective 2025-02-01. | |
| Timely filing | Pass | Received 36 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 (2354462238). | |
| 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 Associates2026-04-28 17:12
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023941 | 2026-03-29 | Riverside Digestive Health Center | $324.00 | Approved |
| CLM-2026-012138 | 2026-03-22 | Sunrise Skin Care Associates | $265.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.