CLM-2026-034438
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-06-18 at independent laboratory (POS 81). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Betty Sandoval
- Member ID
- UHC-13305-47
- Date of birth
- 1944-09-25
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-429963
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2947
- Coverage period
- 2023-05-01 to 2026-05-26
- Deductible
- $2,107.39 of $3,500.0060%
- Out-of-pocket maximum
- $650.66 of $7,000.009%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $65.00 | $40.30 | — | — | DeniedCO27 |
| 2 | 80061 | Lipid panel | 25 | 1 | 1 | $85.00 | $52.70 | — | — | DeniedCO27 |
| 3 | 85025 | Complete blood count with differential | 25 | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO27 |
| Totals | $213.00 | $132.06 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-469306
- 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-023917 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-18 is after coverage terminated on 2026-05-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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) | 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 Clinical Laboratories2026-06-18 15:22
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-07-08 06:49
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-08 10:46
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-18 is after coverage terminated on 2026-05-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014401 | 2026-08-20 | Heritage Medical Group | $194.00 | Denied |
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
Service after coverage termination.