CLM-2026-017413
Evergreen Medical Group, Family Medicine. Service 2026-08-18 at office (POS 11). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Willie Garcia
- Member ID
- UHC-41138-39
- Date of birth
- 1939-05-09
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-419452
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3309
- Coverage period
- 2024-03-01 to present
- Deductible
- $337.21 of $1,000.0034%
- Out-of-pocket maximum
- $148.76 of $2,000.007%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3925619678
- Network
- In network
- Rendering NPI
- 1184329252
- Location
- Phoenix, AZ · TIN 51-3095998
- 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 | $231.00 | $143.22 | $30.00 | $113.22 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $15.00 | $9.30 | $0.00 | $9.30 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $255.00 | $158.10 | $0.00 | $158.10 | Paid |
| Totals | $501.00 | $310.62 | $30.00 | $280.62 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-159323
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000541 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-18: SELECT-EPO (EPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 15 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 (3925619678). | |
| 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 Group2026-08-18 09:33
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028098 | 2026-09-07 | Northgate Imaging Center | $546.00 | Denied |
| CLM-2026-028847 | 2026-06-01 | Sunrise Internal Medicine Associates | $398.00 | 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.