CLM-2026-022623
Evergreen Family Practice, Family Medicine. Service 2026-02-23 at office (POS 11). Received 2026-03-16.
Member
Resolved through the identity graph
- Member
- Jesse Ramos
- Member ID
- UHC-31567-09
- Date of birth
- 2008-04-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-425669
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7814
- Coverage period
- 2021-06-01 to present
- Deductible
- $361.97 of $500.0072%
- Out-of-pocket maximum
- $837.94 of $2,000.0042%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9703652849
- Network
- In network
- Rendering NPI
- 1827765433
- Location
- Miami, FL · TIN 83-6828766
- 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 | 36415 | Venipuncture | — | 1 | 1 | $17.00 | $10.54 | $10.54 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $185.00 | $114.70 | $0.00 | $114.70 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $249.00 | $154.38 | $0.00 | $154.38 | Paid |
| Totals | $451.00 | $279.62 | $10.54 | $269.08 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-139076
- 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-020112 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-23: MEDICARE-ADV-A (MA), effective 2021-06-01. | |
| Timely filing | Pass | Received 21 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 (9703652849). | |
| 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 Practice2026-02-23 10:38
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-16 05:42
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-139076.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
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
Authorisation must be confirmed with UM before payment.