CLM-2026-026966
Evergreen Medical Group, Internal Medicine. Service 2026-03-23 at office (POS 11). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Sara Alvarado
- Member ID
- UHC-57137-88
- Date of birth
- 1994-08-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419776
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6095
- Coverage period
- 2021-01-01 to 2026-01-10
- Deductible
- $169.04 of $500.0034%
- Out-of-pocket maximum
- $848.09 of $2,000.0042%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4796859906
- Network
- Out of network
- Rendering NPI
- 6153056596
- Location
- Denver, CO · TIN 29-0340886
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $94.00 | $42.30 | — | — | DeniedCO27 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $347.00 | $156.15 | — | — | DeniedCO27 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $213.00 | $95.85 | — | — | DeniedCO27 |
| Totals | $654.00 | $294.30 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-927163
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023423 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-23 is after coverage terminated on 2026-01-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 Group2026-03-23 13:42
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-27 01:44
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-27 16:20
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-23 is after coverage terminated on 2026-01-10. 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
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.