CLM-2026-018607
Evergreen Primary Care Associates, Family Medicine. Service 2026-06-28 at office (POS 11). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Sam Maldonado
- Member ID
- UHC-98202-14
- Date of birth
- 1981-09-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422862
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group N/A
- Coverage period
- 2023-04-01 to 2026-01-11
- Deductible
- $258.54 of $2,500.0010%
- Out-of-pocket maximum
- $1,502.13 of $5,000.0030%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2959091630
- Network
- In network
- Rendering NPI
- 7431042523
- 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 | 90471 | Immunization administration | — | 1 | 1 | $33.00 | $20.46 | — | — | DeniedCO27 |
| Totals | $33.00 | $20.46 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-456079
- 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-041283 (provisional, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-28 is after coverage terminated on 2026-01-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 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 Associates2026-06-28 12:27
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-12 05:48
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 2026-06-28 is after coverage terminated on 2026-01-11.
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.