CLM-2026-017845
Evergreen Medical Group, Internal Medicine. Service 2026-08-01 at office (POS 11). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Hannah Fox
- Member ID
- UHC-68631-94
- Date of birth
- 1957-02-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-411914
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6938
- Coverage period
- 2024-07-01 to 2026-06-25
- Deductible
- $217.06 of $1,000.0022%
- Out-of-pocket maximum
- $1,706.70 of $4,000.0043%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 1617180553
- Location
- Denver, CO · TIN 29-0340886
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $351.00 | $157.95 | — | — | DeniedCO27 |
| Totals | $351.00 | $157.95 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-322998
- 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-036315 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-01 is after coverage terminated on 2026-06-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Group2026-08-01 15:26
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-04 06:27
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 2026-08-01 is after coverage terminated on 2026-06-25. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.