CLM-2026-023389
Evergreen Medical Group, Internal Medicine. Service 2026-05-23 at office (POS 11). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Andrea Whhite
- Member ID
- UHC-79988-26
- Date of birth
- 1951-07-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423762
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6543
- Coverage period
- 2022-04-01 to present
- Deductible
- $78.85 of $500.0016%
- Out-of-pocket maximum
- $480.05 of $1,000.0048%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 2857398285
- Location
- Denver, CO · TIN 29-0340886
- Authorisation / referral
- none / REF281607
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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $342.00 | $153.90 | — | — | DeniedCO204 |
| Totals | $342.00 | $153.90 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-639020
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-036394 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-23: NAVIGATE-HMO (HMO), effective 2022-04-01. | |
| Timely filing | Pass | Received 34 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 | Fail | CO204 | Billing provider 4796859906 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Group2026-05-23 13:25
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-06-26 04:55
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 4796859906 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034036 | 2026-04-22 | Harbor Medical Group | $219.00 | 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
No out-of-network benefit on this plan.