CLM-2026-002890
Evergreen Diagnostic Imaging, Radiology. Service 2026-06-15 at outpatient hospital (POS 22). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Juan Carlson
- Member ID
- UHC-78684-93
- Date of birth
- 1973-08-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431811
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9378
- Coverage period
- 2021-04-01 to present
- Deductible
- $1,450.57 of $3,500.0041%
- Out-of-pocket maximum
- $1,855.39 of $7,000.0027%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- none / REF244106
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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $141.00 | $77.55 | — | — | Review |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 2 | $407.00 | $223.85 | — | — | Review |
| Totals | $548.00 | $301.40 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-691665
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032235 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-15: NAVIGATE-HMO (HMO), effective 2021-04-01. | |
| Timely filing | Pass | Received 38 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 Diagnostic Imaging (7098075170). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Diagnostic Imaging2026-06-15 14:36
Patient seen for pain in right knee. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-23 00:32
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-691665.pdf5 pages
Itemised statement totalling $548.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”.
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
Development letter outstanding.