CLM-2026-012898
Evergreen Medical Group, Internal Medicine. Service 2026-01-20 at office (POS 11). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Peterson Marilyn
- Member ID
- UHC-78588-21
- Date of birth
- 1942-12-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-413028
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-5480
- Coverage period
- 2021-06-01 to present
- Deductible
- $164.67 of $1,500.0011%
- Out-of-pocket maximum
- $475.41 of $3,000.0016%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 5172064383
- Location
- Denver, CO · TIN 29-0340886
- 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 | $268.00 | $120.60 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $303.00 | $136.35 | — | — | Review |
| Totals | $571.00 | $256.95 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-363909
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016785 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-20: UNKNOWN (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 40 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Medical Group2026-01-20 18:29
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-01 04:56
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-01 09:51
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 engineReview2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Development letter outstanding.