CLM-2026-020540
Evergreen Medical Group, Family Medicine. Service 2026-02-14 at office (POS 11). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Nancy Freeman
- Member ID
- UHC-64096-58
- Date of birth
- 1991-07-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420923
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4610
- Coverage period
- 2022-12-01 to present
- Deductible
- $344.21 of $1,500.0023%
- Out-of-pocket maximum
- $670.20 of $3,000.0022%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3925619678
- Network
- In network
- Rendering NPI
- 8639368868
- Location
- Phoenix, AZ · TIN 51-3095998
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $190.00 | $117.80 | $25.00 | $92.80 | Paid |
| Totals | $190.00 | $117.80 | $25.00 | $92.80 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-568184
- 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-018356 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-14: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 22 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 Medical Group (3925619678). | |
| 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 Medical Group2026-02-14 15:08
Patient seen for type 2 diabetes mellitus without complications.
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-2026-027176 | 2026-03-31 | Valley Medical Group | $211.00 | 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.