CLM-2026-016881
Evergreen Primary Care Associates, Family Medicine. Service 2025-06-24 at office (POS 11). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Harold Bishop
- Member ID
- UHC-58284-64
- Date of birth
- 2006-05-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409425
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9823
- Coverage period
- 2025-08-01 to present
- Deductible
- $2,286.80 of $3,500.0065%
- Out-of-pocket maximum
- $2,865.30 of $10,500.0027%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2959091630
- Network
- In network
- Rendering NPI
- 2725772745
- Location
- Denver, CO · TIN 46-9380286
- 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 | $177.00 | $109.74 | — | — | DeniedN30 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $23.00 | $14.26 | — | — | DeniedN30 |
| Totals | $200.00 | $124.00 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-365504
- 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-000162 (verified, link confidence 0.99). | |
| Eligibility | Fail | N30 | Date of service 2025-06-24 is before coverage effective date 2025-08-01. Patient ineligible for this service |
| Timely filing | Fail | CO29 | Received 191 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Primary Care Associates (2959091630). | |
| 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 Primary Care Associates2025-06-24 17:37
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-01-01 00:59
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2025-06-24 is before coverage effective date 2025-08-01. Timely filing: Received 191 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000731 | 2026-09-22 | Heritage Family Practice | $157.00 | 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
Received after the timely-filing limit.