CLM-2026-002402
Evergreen Internal Medicine Associates, Internal Medicine. Service 2025-12-09 at office (POS 11). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Arthur Wong
- Member ID
- UHC-99527-30
- Date of birth
- 1975-07-15
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428492
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group -
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,246.53 of $2,500.0090%
- Out-of-pocket maximum
- $1,273.81 of $7,500.0017%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8561588111
- Network
- In network
- Rendering NPI
- 5504029484
- Location
- Nashville, TN · TIN 40-5460828
- 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 | $287.00 | $177.94 | — | — | PendedIDQ |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $83.00 | $51.46 | — | — | PendedIDQ |
| Totals | $370.00 | $229.40 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. J44.9 COPD, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-898490
- 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 | Fail | IDQ | Member record is in open steward case CASE-001570; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-12-09: NULL (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 41 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 | Pass | In-network provider Evergreen Internal Medicine Associates (8561588111). | |
| 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 Internal Medicine Associates2025-12-09 18:35
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001570; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.