CLM-2026-015907
Evergreen Medical Group, Family Medicine. Service 2026-05-18 at office (POS 11). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Kayla McDonald
- Member ID
- UHC-78221-66
- Date of birth
- 2004-09-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419314
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9376
- Coverage period
- 2024-05-01 to present
- Deductible
- $2,963.06 of $3,500.0085%
- Out-of-pocket maximum
- $4,169.78 of $14,000.0030%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2175082280
- Network
- In network
- Rendering NPI
- 7150522754
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $199.00 | $123.38 | — | — | DeniedCO18 |
| 2 | 90471 | Immunization administration | 25 | 1 | 1 | $39.00 | $24.18 | — | — | DeniedCO18 |
| Totals | $238.00 | $147.56 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-985437
- 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-028176 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-18: NULL (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-015906: 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 Group2026-05-18 11:00
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-06-07 01:14
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-07 17:56
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-015906: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015906 | 2026-05-18 | Evergreen Medical Group | $238.00 | 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.