CLM-2026-016890
Evergreen Internal Medicine Associates, Internal Medicine. Service 2026-02-05 at office (POS 11). Received 2026-05-13.
Member
Resolved through the identity graph
- Member
- Joyce Baker
- Member ID
- UHC-28092-57
- Date of birth
- 1946-03-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-429079
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-4337
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,328.04 of $1,500.0089%
- Out-of-pocket maximum
- $612.82 of $4,500.0014%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8561588111
- Network
- In network
- Rendering NPI
- 4066132364
- Location
- Nashville, TN · TIN 40-5460828
- 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 | $263.00 | $163.06 | — | — | DeniedCO29 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $282.00 | $174.84 | — | — | DeniedCO29 |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 1,2 | $60.00 | $37.20 | — | — | DeniedCO29 |
| Totals | $605.00 | $375.10 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-730727
- 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-005892 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-05: N/A (PPO), effective 2021-11-01. | |
| Timely filing | Fail | CO29 | Received 97 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 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 Associates2026-02-05 16:08
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-13 04:29
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 12:44Timely filing: Received 97 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026653 | 2026-07-13 | Heritage GI Associates | $300.00 | Approved |
| CLM-2026-013739 | 2026-01-03 | Canyon Medical Group | $274.00 | 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.