CLM-2026-001220
Evergreen Family Practice, Family Medicine. Service 2026-08-31 at office (POS 11). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Gloria Martin
- Member ID
- UHC-38570-43
- Date of birth
- 1989-09-15
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-429714
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6616
- Coverage period
- 2025-08-01 to present
- Deductible
- $299.88 of $500.0060%
- Out-of-pocket maximum
- $353.29 of $2,000.0018%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5857456904
- Network
- In network
- Rendering NPI
- 3482481264
- Location
- Austin, TX · TIN 44-5200426
- 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 | $324.00 | $200.88 | — | — | Review |
| Totals | $324.00 | $200.88 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-504890
- 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-004710 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-31: MEDICARE-ADV-B (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-001219, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Family Practice (5857456904). | |
| 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 Family Practice2026-08-31 12:47
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-10-15 01:30
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-15 10:47
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-001219, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001219 | 2026-08-31 | Northgate Medical Group | $324.00 | Approved |
| CLM-2026-008562 | 2026-04-23 | Summit Community Hospital | $1,033.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.