CLM-2026-019682
Evergreen Primary Care Associates, Family Medicine. Service 2026-04-16 at office (POS 11). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Amber Wells
- Member ID
- UHC-80479-97
- Date of birth
- 1953-04-11
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-423453
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6435
- Coverage period
- 2022-03-01 to present
- Deductible
- $697.45 of $2,500.0028%
- Out-of-pocket maximum
- $3,397.11 of $7,500.0045%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 7464749929
- Network
- In network
- Rendering NPI
- 1533716787
- Location
- Austin, TX · TIN 79-4124190
- 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 | — | — | Review |
| Totals | $33.00 | $20.46 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-113001
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002456 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-16: OPTIONS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-019681, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Primary Care Associates (7464749929). | |
| 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 Associates2026-04-16 13:27
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-05-18 03:52
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-18 12:11
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-019681, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011839 | 2026-09-13 | Heritage Medical Group | $163.00 | Denied |
| CLM-2026-011838 | 2026-09-13 | Heritage Medical Group | $163.00 | Approved |
| CLM-2026-019681 | 2026-04-16 | Evergreen Medical Group | $33.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Different billing provider; separately payable.