CLM-2026-019251
Evergreen Diagnostic Imaging, Radiology. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Jeremy Fernandez
- Member ID
- UHC-82545-81
- Date of birth
- 1942-06-17
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414915
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0714
- Coverage period
- 2023-09-01 to present
- Deductible
- $290.71 of $500.0058%
- Out-of-pocket maximum
- $514.69 of $2,000.0026%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $394.00 | $216.70 | $210.77 | $5.93 | Paid |
| Totals | $394.00 | $216.70 | $210.77 | $5.93 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-567491
- 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-017749 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-25: OPTIONS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 40 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 Diagnostic Imaging (7098075170). | |
| 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 Diagnostic Imaging2026-01-25 18:10
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-567491.pdf2 pages
Itemised statement totalling $394.00 across 1 line.
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
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.