CLM-2026-012878
Evergreen Medical Group, Family Medicine. Service 2025-12-19 at office (POS 11). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Margaret Freeman
- Member ID
- UHC-69240-19
- Date of birth
- 2007-05-19
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-429145
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6965
- Coverage period
- 2021-11-01 to present
- Deductible
- $243.98 of $1,500.0016%
- Out-of-pocket maximum
- $2,205.75 of $4,500.0049%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5318093783
- Network
- In network
- Rendering NPI
- 4039946627
- 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 | 59 | 1 | 1 | $247.00 | $153.14 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 2 | $200.00 | $124.00 | — | — | Review |
| Totals | $447.00 | $277.14 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-748043
- 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-004009 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-19: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 25 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2025-12-19 10:24
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-13 04:43
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-748043.pdf17 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationApproved2026-10-23 17:08The claim is for an office visit with a new and an established patient, both at low complexity. The provider is in-network, and the member is eligible. The claim passed all deterministic rules except for an NCCI edit due to the use of modifier 59 on a normally bundled code pair. However, the clinical note and operative note confirm that the procedures were performed at distinct anatomical sites, justifying the use of modifier 59. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:43 · 2d47a998
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 17:08 · 7309395d
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for an office visit with a new and an established patient, both at low complexity. The provider is in-network, and the member is eligible. The claim passed all deterministic rules except for an NCCI edit due to the use of modifier 59 on a normally bundled code pair. However, the clinical note and operative note confirm that the procedures were performed at distinct anatomical sites, justifying the use of modifier 59. Therefore, the claim is approved.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.