CLM-2026-018765
Evergreen Family Practice, Family Medicine. Service 2026-08-20 at office (POS 11). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Shirley Rojas
- Member ID
- UHC-61087-91
- Date of birth
- 1966-01-02
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-429663
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-9951
- Coverage period
- 2024-03-01 to present
- Deductible
- $414.17 of $2,500.0017%
- Out-of-pocket maximum
- $2,112.25 of $5,000.0042%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9423912895
- Network
- In network
- Rendering NPI
- 9540017727
- Location
- Austin, TX · TIN 10-8497097
- 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 | $276.00 | $171.12 | $25.00 | $146.12 | Paid |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $27.00 | $16.74 | $0.00 | $16.74 | Paid |
| 3 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $217.00 | $134.54 | $0.00 | $134.54 | Paid |
| Totals | $520.00 | $322.40 | $25.00 | $297.40 | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-572989
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034425 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-20: N/A (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 43 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 Family Practice (9423912895). | |
| 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 Family Practice2026-08-20 15:35
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004660 | 2026-08-28 | Evergreen Medical Group | $575.00 | Approved |
| CLM-2026-033183 | 2026-08-04 | Evergreen Medical Group | $238.00 | 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.