CLM-2026-020253
Evergreen Family Practice, Family Medicine. Service 2026-06-20 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Anna Ward
- Member ID
- UHC-23557-50
- Date of birth
- 1948-12-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400727
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7685
- Coverage period
- 2024-02-01 to 2026-02-11
- Deductible
- $658.30 of $1,500.0044%
- Out-of-pocket maximum
- $678.23 of $3,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9423912895
- Network
- In network
- Rendering NPI
- 8244648977
- 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 | $217.00 | $134.54 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | — | — | DeniedCO27 |
| Totals | $240.00 | $148.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-448517
- 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-037079 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-20 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 13 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 Practice2026-06-20 16:11
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-07-03 04:45
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-03 09:14
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-20 is after coverage terminated on 2026-02-11.
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.