CLM-2026-008362
Evergreen Family Practice, Family Medicine. Service 2026-04-15 at office (POS 11). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Juan Williamson
- Member ID
- UHC-85093-20
- Date of birth
- 1956-04-04
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426357
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3769
- Coverage period
- 2023-05-01 to present
- Deductible
- $86.02 of $500.0017%
- Out-of-pocket maximum
- $406.63 of $1,000.0041%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- 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
- 1734337631
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $202.00 | $125.24 | $20.00 | $105.24 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $199.00 | $123.38 | $0.00 | $123.38 | Paid |
| Totals | $401.00 | $248.62 | $20.00 | $228.62 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-396508
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032483 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-15: CHOICE-PLUS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 42 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) | 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 Practice2026-04-15 13:00
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008363 | 2026-04-15 | Evergreen Family Practice | $401.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.