CLM-2026-034050
Northgate Medical Group, Internal Medicine. Service 2026-06-12 at office (POS 11). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Diego Bradley
- Member ID
- UHC-63626-44
- Date of birth
- 1981-06-15
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-405410
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1894
- Coverage period
- 2021-01-01 to present
- Deductible
- $490.44 of $3,500.0014%
- Out-of-pocket maximum
- $1,685.74 of $10,500.0016%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 5749254103
- Network
- In network
- Rendering NPI
- 3395190697
- Location
- Dallas, TX · TIN 90-6599797
- Authorisation / referral
- none / REF544428
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 | $235.00 | $145.70 | $40.00 | $105.70 | Paid |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $79.00 | $48.98 | $0.00 | $48.98 | Paid |
| Totals | $314.00 | $194.68 | $40.00 | $154.68 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-390493
- 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-017284 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-12: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 6 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 Medical Group (5749254103). | |
| 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 Medical Group2026-06-12 09:51
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
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-2026-020826 | 2026-07-26 | Harbor Physical Therapy | $237.00 | Approved |
| CLM-2026-021840 | 2026-06-11 | Sunrise Skin Care Associates | $165.00 | 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.