CLM-2026-009829
Evergreen Medical Group, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Eugene Sanchez
- Member ID
- UHC-25758-11
- Date of birth
- 1966-10-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405034
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6054
- Coverage period
- 2025-04-01 to present
- Deductible
- $348.21 of $1,500.0023%
- Out-of-pocket maximum
- $302.01 of $6,000.005%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3925619678
- Network
- In network
- Rendering NPI
- 9026336435
- Location
- Phoenix, AZ · TIN 51-3095998
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $267.00 | $165.54 | $20.00 | $145.54 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $227.00 | $140.74 | $0.00 | $140.74 | Paid |
| Totals | $494.00 | $306.28 | $20.00 | $286.28 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-269416
- 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-014681 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-12: N/A (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 43 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 (3925619678). | |
| 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 Group2026-05-12 13:52
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
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.