CLM-2026-025535
Evergreen Family Practice, Family Medicine. Service 2026-04-04 at office (POS 11). Received 2026-08-11.
Member
Resolved through the identity graph
- Member
- Eugene Graham
- Member ID
- UHC-44398-20
- Date of birth
- 2004-10-26
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-417683
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9689
- Coverage period
- 2025-10-01 to present
- Deductible
- $423.46 of $500.0085%
- Out-of-pocket maximum
- $402.79 of $2,000.0020%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5857456904
- Network
- In network
- Rendering NPI
- 2181734486
- Location
- Austin, TX · TIN 44-5200426
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $237.00 | $146.94 | — | — | DeniedCO29 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $247.00 | $153.14 | — | — | DeniedCO29 |
| Totals | $484.00 | $300.08 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. M54.50 Low back pain, unspecified
- 3. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-253108
- 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-022104 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-04: MEDICARE-ADV-A (MA), effective 2025-10-01. | |
| Timely filing | Fail | CO29 | Received 129 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (5857456904). | |
| 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 Practice2026-04-04 09:27
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-11 06:19
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-11 16:23
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 129 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.