CLM-2026-026810
Evergreen Medical Group, Internal Medicine. Service 2026-01-26 to 2026-01-27 at inpatient hospital (POS 21). Received 2026-02-28.
Member
Resolved through the identity graph
- Member
- Sandra Kim
- Member ID
- UHC-76520-73
- Date of birth
- 1996-01-07
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-404443
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7130
- Coverage period
- 2024-08-01 to 2026-01-14
- Deductible
- $37.30 of $500.007%
- Out-of-pocket maximum
- $74.69 of $1,000.007%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 4805861786
- 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 | $179.00 | $80.55 | — | — | DeniedCO27 |
| Totals | $179.00 | $80.55 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-903818
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-01-26 to 2026-01-29
- 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-000585 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-26 is after coverage terminated on 2026-01-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 32 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 | 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 Group2026-01-27 14:28
Established patient presents with copd, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-28 02:06
Attachments
Documents received with the claim
- Itemized billitemized_PA-903818.pdf8 pages
Itemised statement totalling $179.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-26 is after coverage terminated on 2026-01-14. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005606 | 2026-02-22 | Meadow Heart Institute | $1,456.00 | Denied |
| CLM-2026-024670 | 2026-01-18 | Meadow Family Practice | $542.00 | Denied |
| CLM-2026-021910 | 2025-12-04 | Canyon Primary Care Associates | $142.00 | Approved |
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
Service after coverage termination.