CLM-2026-033123
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-09-06 at independent laboratory (POS 81). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Noah Oliver
- Member ID
- UHC-49295-92
- Date of birth
- 1942-01-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404924
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9734
- Coverage period
- 2024-12-01 to present
- Deductible
- $149.61 of $500.0030%
- Out-of-pocket maximum
- $294.25 of $2,000.0015%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9874235952
- Network
- In network
- Rendering NPI
- 9874235952
- Location
- Charlotte, NC · TIN 55-1691702
- 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 | 80061 | Lipid panel | 59 | 1 | 1 | $39.00 | $24.18 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | 59 | 1 | 1,2 | $55.00 | $34.10 | — | — | Review |
| Totals | $94.00 | $58.28 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-244356
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027437 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-06: MEDICARE-ADV-A (MA), effective 2024-12-01. | |
| Timely filing | Pass | Received 28 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 Clinical Laboratories (9874235952). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Clinical Laboratories2026-09-06 15:07
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-10-04 04:51
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-04 11:30
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-244356.pdf4 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.