CLM-2026-002460
Evergreen Family Practice, Family Medicine. Service 2026-02-08 at office (POS 11). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- Aaron Berry
- Member ID
- UHC-34568-51
- Date of birth
- 1972-03-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-419618
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7662
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,075.41 of $3,500.0031%
- Out-of-pocket maximum
- $5,245.30 of $14,000.0037%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 3200447456
- Location
- Los Angeles, CA · TIN 10-4370039
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $260.00 | $161.20 | $30.00 | $131.20 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $313.00 | $194.06 | $0.00 | $194.06 | Paid |
| 3 | 36415 | Venipuncture | — | 1 | 1,2 | $15.00 | $9.30 | $0.00 | $9.30 | Paid |
| Totals | $588.00 | $364.56 | $30.00 | $334.56 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-102528
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019637 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-08: NULL (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 34 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 Family Practice (1600303576). | |
| 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 Practice2026-02-08 17:31
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029297 | 2026-02-18 | Mesa Clinical Laboratories | $129.00 | Approved |
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.