CLM-2026-027253
Evergreen Medical Group, Family Medicine. Service 2026-05-20 at office (POS 11). Received 2026-06-03.
Member
Resolved through the identity graph
- Member
- Nicole Evans
- Member ID
- UHC-84542-04
- Date of birth
- 1960-04-28
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-425610
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group N/A
- Coverage period
- 2024-06-01 to 2026-04-24
- Deductible
- $710.96 of $1,000.0071%
- Out-of-pocket maximum
- $1,332.11 of $4,000.0033%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2175082280
- Network
- In network
- Rendering NPI
- 5816064583
- Location
- Scottsdale, AZ · TIN 79-9933181
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $144.00 | $89.28 | — | — | DeniedCO27 |
| Totals | $144.00 | $89.28 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-585827
- 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-033414 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-20 is after coverage terminated on 2026-04-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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 (2175082280). | |
| 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 Group2026-05-20 12:41
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-03 03:27
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 2026-05-20 is after coverage terminated on 2026-04-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017886 | 2026-08-05 | Mesa Diabetes Center | $212.00 | Denied |
| CLM-2026-007630 | 2026-07-27 | Summit Clinical Laboratories | $44.00 | Denied |
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.