Professional claim · CMS-1500 · EDI 837P
CLM-2026-032084
Northgate Internal Medicine Associates, Internal Medicine. Service 2026-08-19 at office (POS 11). Received 2026-08-31.
Approved
Billed
$691.00
2 lines
Allowed
$428.42
contract rate applied
Plan pays
$388.42
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Billy Barnes
- Member ID
- UHC-81889-78
- Date of birth
- 1995-06-25
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-404474
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6960
- Coverage period
- 2021-11-01 to present
- Deductible
- $223.92 of $1,000.0022%
- Out-of-pocket maximum
- $511.64 of $4,000.0013%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 5325375595
- Network
- In network
- Rendering NPI
- 8861050333
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $310.00 | $192.20 | $40.00 | $152.20 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $381.00 | $236.22 | $0.00 | $236.22 | Paid |
| Totals | $691.00 | $428.42 | $40.00 | $388.42 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
Claim header
- Patient account
- PA-638943
- 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-002113 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-19: N/A (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 12 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Internal Medicine Associates2026-08-19 09:28
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$691.00
Plan discount
$262.58
contracted rate
Plan paid
$388.42
You may owe
$40.00
copay, deductible and coinsurance
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-2026-021945 | 2026-07-29 | Heritage Primary Care Associates | $268.00 | Approved |
| CLM-2026-011331 | 2026-05-26 | Summit Clinical Laboratories | $93.00 | Approved |
| CLM-2026-027619 | 2025-12-12 | Northgate Clinical Laboratories | $164.00 | Approved |
| CLM-2026-002452 | 2025-12-13 | Meadow Imaging Center | $4,496.00 | Approved |
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.