CLM-2026-016060
Evergreen Medical Group, Family Medicine. Service 2026-09-22 at office (POS 11). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Oliver Linda
- Member ID
- UHC-29977-44
- Date of birth
- 1983-11-25
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-402761
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2593
- Coverage period
- 2023-11-01 to 2026-02-02
- Deductible
- $733.80 of $1,000.0073%
- Out-of-pocket maximum
- $215.53 of $2,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5318093783
- Network
- In network
- Rendering NPI
- 4883967240
- 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 | — | 1 | 1 | $203.00 | $125.86 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $257.00 | $159.34 | — | — | DeniedCO27 |
| Totals | $460.00 | $285.20 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-178497
- 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-031996 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-22 is after coverage terminated on 2026-02-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 17 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) | 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 Group2026-09-22 12:55
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-09 06:34
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-09 16:52
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-22 is after coverage terminated on 2026-02-02.
Other claims for this member
Same resolved identity
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
Service after coverage termination.