CLM-2026-007377
Evergreen Medical Group, Family Medicine. Service 2026-08-30 at office (POS 11). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Christine James
- Member ID
- UHC-20756-55
- Date of birth
- 2004-08-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423111
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2133
- Coverage period
- 2022-01-01 to 2026-08-18
- Deductible
- $1,111.98 of $1,500.0074%
- Out-of-pocket maximum
- $443.31 of $3,000.0015%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2175082280
- Network
- In network
- Rendering NPI
- 2938967397
- Location
- Scottsdale, AZ · TIN 79-9933181
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $163.00 | $101.06 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 1,2 | $24.00 | $14.88 | — | — | DeniedCO27 |
| Totals | $187.00 | $115.94 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-324127
- 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-004560 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-30 is after coverage terminated on 2026-08-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 Medical Group (2175082280). | |
| 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 Group2026-08-30 09:42
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-27 01:10
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-30 is after coverage terminated on 2026-08-18.
Other claims for this member
Same resolved identity
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
Service after coverage termination.