CLM-2026-011958
Evergreen Medical Group, Family Medicine. Service 2026-07-31 at office (POS 11). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Sharon Jordan
- Member ID
- UHC-95905-11
- Date of birth
- 1940-10-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-412665
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5478
- Coverage period
- 2025-01-01 to present
- Deductible
- $853.75 of $1,500.0057%
- Out-of-pocket maximum
- $1,117.96 of $3,000.0037%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5318093783
- Network
- In network
- Rendering NPI
- 8415122729
- Location
- Dallas, TX · TIN 84-3883832
- 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 | $194.00 | $120.28 | $25.00 | $95.28 | Paid |
| Totals | $194.00 | $120.28 | $25.00 | $95.28 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-787801
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002563 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-31: CORE-HMO (HMO), effective 2025-01-01. | |
| Timely filing | Pass | Received 39 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 (5318093783). | |
| 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 Group2026-07-31 11:14
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007558 | 2026-01-09 | Lakeside Medical Group | $28.00 | Approved |
| CLM-2026-028359 | 2025-12-03 | Pinecrest Diagnostic Imaging | $2,988.00 | Approved |
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.