CLM-2026-012623
Evergreen Medical Group, Family Medicine. Service 2026-08-01 at office (POS 11). Received 2026-08-22.
Member
Resolved through the identity graph
- Member
- Alan Contreras
- Member ID
- UHC-91768-91
- Date of birth
- 1948-01-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429306
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8906
- Coverage period
- 2021-03-01 to present
- Deductible
- $273.36 of $500.0055%
- Out-of-pocket maximum
- $444.00 of $1,500.0030%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2175082280
- Network
- In network
- Rendering NPI
- 5777667135
- Location
- Scottsdale, AZ · TIN 79-9933181
- 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 | $260.00 | $161.20 | — | — | DeniedCO18 |
| Totals | $260.00 | $161.20 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-731329
- 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-032265 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-01: MEDICARE-ADV-A (MA), effective 2021-03-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012622: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Medical Group (2175082280). | |
| 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 Group2026-08-01 15:34
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-22 01:40
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-22 14:03
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-012622: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012622 | 2026-08-01 | Evergreen Medical Group | $260.00 | Approved |
| CLM-2026-029102 | 2026-05-06 | Mesa Physical Therapy | $366.00 | Approved |
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
Exact duplicate of an earlier submission.