CLM-2026-023213
Evergreen Internal Medicine Associates, Internal Medicine. Service 2026-09-14 to 2026-09-15 at inpatient hospital (POS 21). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Lauren Johnston
- Member ID
- UHC-59566-95
- Date of birth
- 1983-11-27
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-423871
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3803
- Coverage period
- 2023-04-01 to 2026-05-22
- Deductible
- $142.89 of $500.0029%
- Out-of-pocket maximum
- $139.97 of $1,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8561588111
- Network
- In network
- Rendering NPI
- 9563260212
- Location
- Nashville, TN · TIN 40-5460828
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $204.00 | $112.20 | — | — | DeniedCO27 |
| Totals | $204.00 | $112.20 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- 3. J44.9 COPD, unspecified
- Patient account
- PA-501690
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-09-14 to 2026-09-18
- 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-027505 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-14 is after coverage terminated on 2026-05-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Internal Medicine Associates (8561588111). | |
| 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 Internal Medicine Associates2026-09-15 18:14
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-23 04:50
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-23 14:26
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-501690.pdf8 pages
Itemised statement totalling $204.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-14 is after coverage terminated on 2026-05-22.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007827 | 2026-05-27 | Sunrise Medical Group | $77.00 | Denied |
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.