CLM-2026-005139
Evergreen Family Practice, Family Medicine. Service 2026-05-14 at office (POS 11). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Susan Burke
- Member ID
- none on golden record
- Date of birth
- 1985-02-25
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-410860
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-7184
- Coverage period
- 2021-07-01 to present
- Deductible
- $426.43 of $500.0085%
- Out-of-pocket maximum
- $64.29 of $1,500.004%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9703652849
- Network
- In network
- Rendering NPI
- 2164281398
- Location
- Miami, FL · TIN 83-6828766
- 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 | $222.00 | $137.64 | — | — | PendedIDQ |
| Totals | $222.00 | $137.64 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-778732
- 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 | Fail | IDQ | Member record is in open steward case CASE-000867; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-05-14: MEDICARE-ADV-A (MA), effective 2021-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 29 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 (9703652849). | |
| 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 Practice2026-05-14 13:45
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000867; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-14: MEDICARE-ADV-A (MA), effective 2021-07-01. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.