CLM-2026-034556
Northgate Clinical Laboratories, Clinical Laboratory. Service 2026-07-11 at independent laboratory (POS 81). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Willie Medina
- Member ID
- UHC-66180-38
- Date of birth
- 2006-07-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403687
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8821
- Coverage period
- 2022-10-01 to present
- Deductible
- $13.59 of $1,000.001%
- Out-of-pocket maximum
- $976.37 of $3,000.0033%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 9320502187
- Network
- In network
- Rendering NPI
- 9320502187
- Location
- Miami, FL · TIN 99-9648979
- 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 | 85025 | Complete blood count with differential | — | 1 | 1 | $43.00 | $26.66 | — | — | DeniedCO18 |
| Totals | $43.00 | $26.66 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-856213
- 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-013919 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-11: MEDICARE-ADV-B (MA), effective 2022-10-01. | |
| Timely filing | Pass | Received 61 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-034555: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Clinical Laboratories (9320502187). | |
| 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 Laboratories2026-07-11 10:45
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-09-10 01:59
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-034555: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034555 | 2026-07-11 | Northgate Clinical Laboratories | $43.00 | Approved |
| CLM-2026-020659 | 2026-05-23 | Valley Bone and Joint Center | $49,930.00 | Needs review |
| CLM-2026-032684 | 2026-01-13 | Mesa Orthopedic Specialists | $193.00 | Approved |
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
Exact duplicate of an earlier submission.