CLM-2026-021613
Evergreen Medical Group, Family Medicine. Service 2026-10-01 at office (POS 11). Received 2026-10-27.
Member
Resolved through the identity graph
- Member
- Adam Garrett
- Member ID
- UHC-27878-40
- Date of birth
- 1986-12-01
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409506
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3997
- Coverage period
- 2022-04-01 to present
- Deductible
- $1,429.93 of $2,500.0057%
- Out-of-pocket maximum
- $1,135.03 of $7,500.0015%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5318093783
- Network
- In network
- Rendering NPI
- 8802225713
- Location
- Dallas, TX · TIN 84-3883832
- 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 | $30.00 | $18.60 | — | — | Review |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 1 | $220.00 | $136.40 | — | — | Review |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $288.00 | $178.56 | — | — | Review |
| Totals | $538.00 | $333.56 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-593958
- 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-018727 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-01: SELECT-EPO (EPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 26 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-2026-021612; 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 Medical Group (5318093783). | |
| 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 Group2026-10-01 10:52
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-10-27 04:41
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-27 15:48
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-021612.pdf1 page
Provider cover letter requesting replacement of CLM-2026-021612.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-021612; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021612 | 2026-10-01 | Evergreen Medical Group | $538.00 | Approved |
| CLM-2026-007996 | 2026-07-29 | Sunrise Community Hospital | $207.00 | Needs review |
| CLM-2026-006705 | 2026-02-05 | Evergreen Dermatology Clinic | $176.00 | Denied |
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
Replacement claim supersedes the original.