CLM-2026-009451
Evergreen Family Practice, Family Medicine. Service 2026-08-28 at office (POS 11). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Will Burton
- Member ID
- UHC-67576-88
- Date of birth
- 1963-03-18
- Identity
- Verified2 records, confidence 0.86
- Claim record
- CLMCLM-421632
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6968
- Coverage period
- 2022-09-01 to 2026-04-23
- Deductible
- $2,304.48 of $3,500.0066%
- Out-of-pocket maximum
- $1,983.38 of $7,000.0028%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9703652849
- Network
- In network
- Rendering NPI
- 5348845947
- 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 | $256.00 | $158.72 | — | — | DeniedCO27 |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $268.00 | $166.16 | — | — | DeniedCO27 |
| Totals | $524.00 | $324.88 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-792936
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015513 (verified, link confidence 0.86). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-28 is after coverage terminated on 2026-04-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 2 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 Practice2026-08-28 09:38
Patient seen for hyperlipidemia, unspecified.
- SystemSystem: Claims system2026-08-30 05:48
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-30 11:11
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-28 is after coverage terminated on 2026-04-23.
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.