Professional claim · CMS-1500 · EDI 837P
CLM-2026-023227
Evergreen Family Practice, Family Medicine. Service 2026-03-03 at office (POS 11). Received 2026-04-01.
Billed
$464.00
2 lines
Allowed
$287.68
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Dnald Grant
- Member ID
- UHC-91776-10
- Date of birth
- 1977-04-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-402003
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group N/A
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,362.65 of $2,500.0055%
- Out-of-pocket maximum
- $998.50 of $7,500.0013%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 6161192474
- Location
- Los Angeles, CA · TIN 10-4370039
- 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 | $258.00 | $159.96 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $206.00 | $127.72 | — | — | PendedIDQ |
| Totals | $464.00 | $287.68 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-869660
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003614; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-03-03: MEDICARE-ADV-B (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 29 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 (1600303576). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Family Practice2026-03-03 16:11
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003614; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.