CLM-2026-026889
Evergreen Family Practice, Family Medicine. Service 2026-03-10 at office (POS 11). Received 2026-03-26.
Member
Resolved through the identity graph
- Member
- Pamela Thompson
- Member ID
- UHC-13349-08
- Date of birth
- 1981-12-15
- Identity
- Verified2 records, confidence 0.90
- Claim record
- CLMCLM-403519
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3369
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,937.20 of $2,500.0077%
- Out-of-pocket maximum
- $4,659.42 of $10,000.0047%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 1366203465
- Location
- Los Angeles, CA · TIN 10-4370039
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $297.00 | $184.14 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $183.00 | $113.46 | — | — | DeniedCO18 |
| Totals | $480.00 | $297.60 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-480478
- 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-019841 (verified, link confidence 0.90). | |
| Eligibility | Pass | Active on 2026-03-10: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026888: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Family Practice (1600303576). | |
| 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 Practice2026-03-10 13:33
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-03-26 04:49
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-026888: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026888 | 2026-03-10 | Evergreen Family Practice | $480.00 | 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
Exact duplicate of an earlier submission.