CLM-2026-002383
Evergreen Diagnostic Imaging, Radiology. Service 2025-12-06 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Marc Allen
- Member ID
- none on golden record
- Date of birth
- 1984-07-06
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-432205
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2022-08-01 to 2026-08-21
- Deductible
- $544.43 of $2,500.0022%
- Out-of-pocket maximum
- $3,651.68 of $10,000.0037%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- PA2025044630 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $352.00 | $193.60 | $193.60 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 2 | $1,213.00 | $667.15 | $667.15 | $0.00 | Paid |
| Totals | $1,565.00 | $860.75 | $860.75 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-324700
- 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-002462 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2025-12-06: OPTIONS-PPO (PPO), effective 2022-08-01, terms 2026-08-21. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025044630 on file for 74177. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| 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 Diagnostic Imaging2025-12-06 09:51
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025044630_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-12-06 to 2026-03-06.
- Itemized billitemized_PA-324700.pdf2 pages
Itemised statement totalling $1565.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2025-12-06: OPTIONS-PPO (PPO), effective 2022-08-01, terms 2026-08-21. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.