Professional claim · CMS-1500 · EDI 837P
CLM-2026-007688
Evergreen Family Practice, Family Medicine. Service 2026-07-13 at office (POS 11). Received 2026-08-10.
Denied
Billed
$569.00
2 lines
Allowed
$352.78
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Arjun Robertson
- Member ID
- UHC-87084-84
- Date of birth
- 1980-11-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416409
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5962
- Coverage period
- 2022-04-01 to 2026-03-18
- Deductible
- $96.87 of $500.0019%
- Out-of-pocket maximum
- $476.91 of $1,000.0048%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 5355943361
- Location
- Los Angeles, CA · TIN 10-4370039
- 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 | 99395 | Preventive visit, 18-39 years | 59 | 1 | 1 | $318.00 | $197.16 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | 59 | 1 | 2 | $251.00 | $155.62 | — | — | DeniedCO27 |
| Totals | $569.00 | $352.78 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-170372
- 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-009602 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-13 is after coverage terminated on 2026-03-18. 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 Family Practice (1600303576). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Family Practice2026-07-13 09:22
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-10 04:20
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-13 is after coverage terminated on 2026-03-18. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025653 | 2026-07-20 | Valley Community Hospital | $880.00 | Denied |
| CLM-2026-023206 | 2026-01-08 | Heritage Physical Therapy | $400.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.