CLM-2026-001070
Evergreen Medical Group, Internal Medicine. Service 2026-06-26 at office (POS 11). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Kayla Gardner
- Member ID
- UHC-98906-09
- Date of birth
- 1963-11-25
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-402712
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2418
- Coverage period
- 2022-07-01 to present
- Deductible
- $846.62 of $1,000.0085%
- Out-of-pocket maximum
- $727.37 of $2,000.0036%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 7912650901
- Location
- Denver, CO · TIN 29-0340886
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $356.00 | $160.20 | — | — | DeniedCO204 |
| Totals | $356.00 | $160.20 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-153758
- 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-036775 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-26: SELECT-EPO (EPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 4 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 | Fail | CO204 | Billing provider 4796859906 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: Evergreen Medical Group2026-06-26 09:44
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-30 05:14
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 4796859906 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009694 | 2026-07-15 | Heritage Clinical Laboratories | $199.00 | Approved |
| CLM-2026-027199 | 2026-06-14 | Valley Primary Care Associates | $641.00 | 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
No out-of-network benefit on this plan.