CLM-2026-025929
Evergreen Medical Group, Internal Medicine. Service 2026-03-09 to 2026-03-11 at inpatient hospital (POS 21). Received 2026-04-08.
Member
Resolved through the identity graph
- Member
- Amy Reed
- Member ID
- UHC-39326-26
- Date of birth
- 1945-12-14
- Identity
- Verified3 records, confidence 0.91
- Claim record
- CLMCLM-405200
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5900
- Coverage period
- 2025-12-01 to present
- Deductible
- $268.83 of $500.0054%
- Out-of-pocket maximum
- $122.78 of $2,000.006%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 7781157970
- Location
- Denver, CO · TIN 29-0340886
- 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 | $162.00 | $72.90 | — | — | Review |
| Totals | $162.00 | $72.90 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. J44.9 COPD, unspecified
- Patient account
- PA-308612
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-09 to 2026-03-11
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013035 (verified, link confidence 0.91). | |
| Eligibility | Pass | Active on 2026-03-09: N/A (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 28 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Medical Group2026-03-11 16:57
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-08 00:21
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-308612.pdf9 pages
Itemised statement totalling $162.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. No”.
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
Development letter outstanding.