CLM-2026-019207
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2025-12-29 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Ann Murray
- Member ID
- UHC-04228-65
- Date of birth
- 1986-04-18
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-407716
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8385
- Coverage period
- 2022-04-01 to present
- Deductible
- $683.67 of $3,500.0020%
- Out-of-pocket maximum
- $523.75 of $14,000.004%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 6346742185
- Location
- Tempe, AZ · TIN 82-7144175
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $229.00 | $141.98 | — | — | Review |
| Totals | $229.00 | $141.98 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-136843
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000797 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-29: CHOICE-PLUS-PPO (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-019206; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Orthopedic Specialists (4479500462). | |
| 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 Orthopedic Specialists2025-12-29 09:18
Patient seen for low back pain, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-08 06:17
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-019206.pdf1 page
Provider cover letter requesting replacement of CLM-2026-019206.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-019206; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-21 14:15This is a replacement claim (frequency code 7) for an earlier claim that was approved. The provider has submitted a corrected claim with a cover letter explaining that the units on line 2 were keyed incorrectly on the original submission. The original claim must be voided when this one adjudicates. The member is eligible, the provider is in-network, and the service is medically necessary. The claim is within the auto-adjudication ceiling and all required documentation is present.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · ef8f9b07
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032490 | 2026-02-14 | Unity Family Practice | $20.00 | Approved |
| CLM-2026-019206 | 2025-12-29 | Evergreen Orthopedic Specialists | $229.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim (frequency code 7) for an earlier claim that was approved. The provider has submitted a corrected claim with a cover letter explaining that the units on line 2 were keyed incorrectly on the original submission. The original claim must be voided when this one adjudicates. The member is eligible, the provider is in-network, and the service is medically necessary. The claim is within the auto-adjudication ceiling and all required documentation is present.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.