CLM-2026-026031
Evergreen Diagnostic Imaging, Radiology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Sam Miller
- Member ID
- UHC-50684-94
- Date of birth
- 1940-11-09
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-404968
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8426
- Coverage period
- 2022-07-01 to present
- Deductible
- $265.58 of $2,500.0011%
- Out-of-pocket maximum
- $893.37 of $10,000.009%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 4970897466
- Network
- In network
- Rendering NPI
- 4970897466
- Location
- Charlotte, NC · TIN 79-7771528
- Authorisation / referral
- none / REF988692
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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $245.00 | $134.75 | $134.75 | $0.00 | Paid |
| Totals | $245.00 | $134.75 | $134.75 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-227091
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006240 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-06: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| 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 | Pass | In-network provider Evergreen Diagnostic Imaging (4970897466). | |
| 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 Diagnostic Imaging2026-08-06 18:22
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Itemized billitemized_PA-227091.pdf6 pages
Itemised statement totalling $245.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008959 | 2026-08-25 | Desert Regional Medical Center | $1,317.00 | Approved |
| CLM-2026-032590 | 2026-06-08 | Harbor Medical Group | $177.00 | Approved |
| CLM-2026-012794 | 2026-03-05 | Lakeside Medical Group | $491.00 | Denied |
| CLM-2026-011453 | 2026-01-07 | Sunrise Behavioral Health | $834.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.