CLM-2026-010122
Evergreen Primary Care Associates, Family Medicine. Service 2026-07-12 at office (POS 11). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Mason Gomez
- Member ID
- UHC-14665-92
- Date of birth
- 1962-04-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-405567
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0166
- Coverage period
- 2023-12-01 to 2026-05-22
- Deductible
- $790.23 of $3,500.0023%
- Out-of-pocket maximum
- $1,680.12 of $7,000.0024%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7464749929
- Network
- In network
- Rendering NPI
- 5161458331
- Location
- Austin, TX · TIN 79-4124190
- 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 | 90471 | Immunization administration | — | 1 | 1 | $38.00 | $23.56 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $254.00 | $157.48 | — | — | DeniedCO27 |
| Totals | $292.00 | $181.04 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-213719
- 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-024559 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-12 is after coverage terminated on 2026-05-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 Primary Care Associates (7464749929). | |
| 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 Primary Care Associates2026-07-12 13:06
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-13 06:28
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-13 08:57
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-12 is after coverage terminated on 2026-05-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004659 | 2026-06-28 | Mesa Physical Therapy | $112.00 | 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.