CLM-2026-003450
Evergreen Medical Group, Internal Medicine. Service 2025-10-22 at office (POS 11). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Nicole Grant
- Member ID
- UHC-12395-95
- Date of birth
- 1957-10-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425751
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2843
- Coverage period
- 2025-01-01 to present
- Deductible
- $178.21 of $1,000.0018%
- Out-of-pocket maximum
- $175.37 of $4,000.004%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 1894448509
- Location
- Denver, CO · TIN 29-0340886
- 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 | $315.00 | $141.75 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $43.00 | $19.35 | — | — | DeniedCO29 |
| 3 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $79.00 | $35.55 | — | — | DeniedCO29 |
| Totals | $437.00 | $196.65 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-925596
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009772 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-22: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Fail | CO29 | Received 151 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Group2025-10-22 10:29
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-22 02:55
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 151 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018906 | 2026-09-08 | Desert Regional Medical Center | $471.00 | Approved |
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.