CLM-2026-001056
Evergreen Primary Care Associates, Family Medicine. Service 2026-06-10 at office (POS 11). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Denise Wilson
- Member ID
- UHC-05747-60
- Date of birth
- 1987-11-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425429
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3487
- Coverage period
- 2023-03-01 to present
- Deductible
- $691.19 of $1,500.0046%
- Out-of-pocket maximum
- $1,062.99 of $3,000.0035%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2959091630
- Network
- In network
- Rendering NPI
- 2687627184
- Location
- Denver, CO · TIN 46-9380286
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $302.00 | $187.24 | — | — | DeniedCO18 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $14.00 | $8.68 | — | — | DeniedCO18 |
| Totals | $316.00 | $195.92 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-298717
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024915 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-10: NULL (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 58 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-001055: 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 Evergreen Primary Care Associates (2959091630). | |
| 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: Evergreen Primary Care Associates2026-06-10 12:22
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-07 02:08
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-001055: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002889 | 2026-09-07 | Heritage Community Hospital | $382.00 | Approved |
| CLM-2026-001055 | 2026-06-10 | Evergreen Primary Care Associates | $316.00 | 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.