CLM-2026-015404
Evergreen Internal Medicine Associates, Internal Medicine. Service 2026-02-20 to 2026-02-23 at inpatient hospital (POS 21). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Bobby Sandoval
- Member ID
- UHC-35265-34
- Date of birth
- 1998-07-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414412
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1998
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,760.58 of $3,500.0050%
- Out-of-pocket maximum
- $6,589.29 of $14,000.0047%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8561588111
- Network
- In network
- Rendering NPI
- 8965117491
- Location
- Nashville, TN · TIN 40-5460828
- Authorisation / referral
- none / none
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 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $230.00 | $126.50 | $126.50 | $0.00 | Paid |
| Totals | $230.00 | $126.50 | $126.50 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
- Patient account
- PA-458408
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-02-20 to 2026-02-21
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016676 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: OPTIONS-PPO (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 6 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 Internal Medicine Associates (8561588111). | |
| 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 Internal Medicine Associates2026-02-23 14:10
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
- Itemized billitemized_PA-458408.pdf8 pages
Itemised statement totalling $230.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021512 | 2026-05-22 | Heritage Primary Care Associates | $259.00 | 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.