CLM-2026-032821
Northgate Reference Lab, Clinical Laboratory. Service 2026-03-22 at independent laboratory (POS 81). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Raymond Baker
- Member ID
- UHC-89971-89
- Date of birth
- 1977-10-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425839
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7936
- Coverage period
- 2021-11-01 to present
- Deductible
- $416.92 of $500.0083%
- Out-of-pocket maximum
- $321.83 of $2,000.0016%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 7207177792
- Network
- In network
- Rendering NPI
- 7207177792
- Location
- Miami, FL · TIN 47-3638402
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $51.00 | $31.62 | $31.62 | $0.00 | Paid |
| 2 | 80061 | Lipid panel | — | 1 | 2 | $55.00 | $34.10 | $34.10 | $0.00 | Paid |
| 3 | 85025 | Complete blood count with differential | — | 1 | 1 | $58.00 | $35.96 | $19.22 | $16.74 | Paid |
| 4 | 83036 | Hemoglobin A1c | — | 1 | 1,2 | $49.00 | $30.38 | $3.04 | $27.34 | Paid |
| Totals | $213.00 | $132.06 | $87.98 | $44.08 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-463791
- 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-020422 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-22: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 5 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 Reference Lab (7207177792). | |
| 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 Reference Lab2026-03-22 17:07
Patient seen for type 2 diabetes mellitus without complications.
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
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.