CLM-2026-010705
Evergreen Diagnostic Imaging, Radiology. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-04-25.
Member
Resolved through the identity graph
- Member
- Judy Perkins
- Member ID
- UHC-49732-53
- Date of birth
- 1981-12-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-421875
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3527
- Coverage period
- 2021-01-01 to 2026-02-06
- Deductible
- $1,907.81 of $3,500.0055%
- Out-of-pocket maximum
- $2,066.26 of $14,000.0015%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- none / REF166375
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $209.00 | $114.95 | — | — | DeniedCO27 |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | 25 | 1 | 2 | $260.00 | $143.00 | — | — | DeniedCO27 |
| Totals | $469.00 | $257.95 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-989785
- 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-027559 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-07 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 18 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 Diagnostic Imaging (4970897466). | |
| 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 Diagnostic Imaging2026-04-07 16:52
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
- SystemSystem: Claims system2026-04-25 03:57
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-25 15:22
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-989785.pdf9 pages
Itemised statement totalling $469.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-07 is after coverage terminated on 2026-02-06.
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.