CLM-2026-002478
Evergreen Medical Group, Internal Medicine. Service 2025-11-03 at office (POS 11). Received 2026-03-11.
Member
Resolved through the identity graph
- Member
- Andrea King
- Member ID
- UHC-14938-22
- Date of birth
- 1960-01-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419252
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6213
- Coverage period
- 2024-11-01 to present
- Deductible
- $2,017.57 of $3,500.0058%
- Out-of-pocket maximum
- $3,346.51 of $7,000.0048%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 7279767926
- Location
- Denver, CO · TIN 29-0340886
- Authorisation / referral
- none / REF649137
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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $60.00 | $27.00 | — | — | DeniedCO29 |
| Totals | $60.00 | $27.00 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-300123
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007281 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-03: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Fail | CO29 | Received 128 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 HMO 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 Group2025-11-03 10:36
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-11 01:42
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-11 14:53
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 128 days after the last date of service (limit 90). Provider network: Billing provider 4796859906 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019299 | 2026-01-25 | Evergreen Medical Group | $416.00 | Denied |
| CLM-2026-028187 | 2026-01-09 | Evergreen Primary Care Associates | $2,772.00 | Needs review |
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
Received after the timely-filing limit.