CLM-2026-033719
Northgate Primary Care Associates, Family Medicine. Service 2026-01-08 at office (POS 11). Received 2026-08-02.
Member
Resolved through the identity graph
- Member
- Debra Mejia
- Member ID
- UHC-43299-12
- Date of birth
- 2004-10-27
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-410262
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4247
- Coverage period
- 2025-07-01 to present
- Deductible
- $869.00 of $3,500.0025%
- Out-of-pocket maximum
- $4,879.53 of $14,000.0035%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 4637508332
- Network
- Out of network
- Rendering NPI
- 5928737308
- Location
- Minneapolis, MN · TIN 67-8207814
- 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 | $284.00 | $127.80 | — | — | DeniedCO29 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $22.00 | $9.90 | — | — | DeniedCO29 |
| Totals | $306.00 | $137.70 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-687846
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014501 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-08: SELECT-EPO (EPO), effective 2025-07-01. | |
| Timely filing | Fail | CO29 | Received 206 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 4637508332 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Primary Care Associates2026-01-08 12:01
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-02 04:24
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-02 12:13
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 206 days after the last date of service (limit 90). Provider network: Billing provider 4637508332 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.