CLM-2026-025330
Evergreen Medical Group, Family Medicine. Service 2026-07-30 at office (POS 11). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Marc Porter
- Member ID
- UHC-51560-94
- Date of birth
- 1949-12-19
- Identity
- Verified2 records, confidence 0.89
- Claim record
- CLMCLM-425335
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3923
- Coverage period
- 2022-03-01 to present
- Deductible
- $1,899.59 of $3,500.0054%
- Out-of-pocket maximum
- $3,127.60 of $10,500.0030%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3925619678
- Network
- In network
- Rendering NPI
- 1916915857
- Location
- Phoenix, AZ · TIN 51-3095998
- 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 | 59 | 1 | 1 | $32.00 | $19.84 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $261.00 | $161.82 | — | — | Review |
| Totals | $293.00 | $181.66 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-647271
- 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 | Pass | Attached to MBR-042061 (verified, link confidence 0.89). | |
| Eligibility | Pass | Active on 2026-07-30: CORE-HMO (HMO), effective 2022-03-01. | |
| 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 Medical Group (3925619678). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-07-30 10:26
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-08-20 01:42
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-20 09:01
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-647271.pdf15 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Bundled code pair; modifier 59 not supported by the operative note.