CLM-2026-010079
Evergreen Family Practice, Family Medicine. Service 2026-07-07 at office (POS 11). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Thomas Espinoza
- Member ID
- UHC-00130-55
- Date of birth
- 2002-10-08
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407313
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7392
- Coverage period
- 2024-09-01 to 2026-03-14
- Deductible
- $254.97 of $500.0051%
- Out-of-pocket maximum
- $998.76 of $2,000.0050%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 8992413871
- 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 | 36415 | Venipuncture | — | 1 | 1 | $21.00 | $13.02 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $210.00 | $130.20 | — | — | DeniedCO27 |
| Totals | $231.00 | $143.22 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-706151
- 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-025808 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-07 is after coverage terminated on 2026-03-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 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) | 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 Practice2026-07-07 10:51
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-12 02:24
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 2026-07-07 is after coverage terminated on 2026-03-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011880 | 2026-07-24 | Lakeside Behavioral Health | $275.00 | Denied |
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.