CLM-2026-005994
Evergreen Family Practice, Family Medicine. Service 2025-12-04 at office (POS 11). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Lori Ferguson
- Member ID
- UHC-87498-51
- Date of birth
- 2006-08-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414189
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8193
- Coverage period
- 2024-02-01 to present
- Deductible
- $58.78 of $500.0012%
- Out-of-pocket maximum
- $778.47 of $2,000.0039%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3736056581
- Network
- In network
- Rendering NPI
- 6575447431
- Location
- Phoenix, AZ · TIN 19-0937993
- 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 | 90471 | Immunization administration | 59 | 1 | 1 | $27.00 | $16.74 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 2 | $197.00 | $122.14 | — | — | Review |
| Totals | $224.00 | $138.88 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-943461
- 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-001450 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-04: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 32 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 (3736056581). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Practice2025-12-04 10:12
Patient seen for hyperlipidemia, unspecified. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-05 06:43
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-05 12:53
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-943461.pdf8 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-21 14:05The claim is for an in-network provider with active coverage. The service lines include an immunization administration and an office visit, both of which are supported by the diagnoses provided. The use of modifier 59 is justified by the clinical note [N1] and the operative note [A1], which document procedures at distinct anatomical sites. All deterministic rules passed, and the claim is within the auto-adjudication ceiling. The evidence pack is complete and supports the claim.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 0d1655da
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an in-network provider with active coverage. The service lines include an immunization administration and an office visit, both of which are supported by the diagnoses provided. The use of modifier 59 is justified by the clinical note [N1] and the operative note [A1], which document procedures at distinct anatomical sites. All deterministic rules passed, and the claim is within the auto-adjudication ceiling. The evidence pack is complete and supports the claim.
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
Modifier 59 supported: distinct anatomical site documented.