CLM-2026-027237
Evergreen Medical Group, Family Medicine. Service 2026-04-13 at office (POS 11). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Christian Ortega
- Member ID
- UHC-71636-16
- Date of birth
- 1969-11-12
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-422115
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5989
- Coverage period
- 2021-01-01 to 2026-03-14
- Deductible
- $994.07 of $3,500.0028%
- Out-of-pocket maximum
- $1,597.68 of $10,500.0015%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3925619678
- Network
- In network
- Rendering NPI
- 8275502895
- Location
- Phoenix, AZ · TIN 51-3095998
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $257.00 | $159.34 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1,2 | $151.00 | $93.62 | — | — | DeniedCO27 |
| Totals | $408.00 | $252.96 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-869569
- 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-027455 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-13 is after coverage terminated on 2026-03-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 Medical Group (3925619678). | |
| 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 Group2026-04-13 13:18
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-07 00:25
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 2026-04-13 is after coverage terminated on 2026-03-14.
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.