CLM-2026-003729
Evergreen Family Practice, Family Medicine. Service 2025-08-14 at office (POS 11). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Betty Vega
- Member ID
- UHC-40806-34
- Date of birth
- 1946-04-04
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-420087
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7064
- Coverage period
- 2025-12-01 to present
- Deductible
- $2,676.77 of $3,500.0076%
- Out-of-pocket maximum
- $6,895.97 of $14,000.0049%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5857456904
- Network
- In network
- Rendering NPI
- 6445301776
- Location
- Austin, TX · TIN 44-5200426
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | — | — | DeniedN30 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $221.00 | $137.02 | — | — | DeniedN30 |
| Totals | $244.00 | $151.28 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-482724
- 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-007544 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | Date of service 2025-08-14 is before coverage effective date 2025-12-01. Patient ineligible for this service |
| Timely filing | Fail | CO29 | Received 164 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 | Pass | In-network provider Evergreen Family Practice (5857456904). | |
| 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 Practice2025-08-14 10:59
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-01-25 01:38
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 12:44Eligibility: Date of service 2025-08-14 is before coverage effective date 2025-12-01. Timely filing: Received 164 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031526 | 2026-07-12 | Summit Medical Group | $117.00 | Approved |
| CLM-2026-018930 | 2026-06-20 | Meadow Family Practice | $499.00 | Approved |
| CLM-2026-001832 | 2026-02-18 | Harbor Medical Group | $180.00 | 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.