CLM-2026-028033
Evergreen Primary Care Associates, Family Medicine. Service 2026-01-01 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Cheryl Pena
- Member ID
- UHC-77349-09
- Date of birth
- 1992-06-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-427295
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3613
- Coverage period
- 2025-01-01 to present
- Deductible
- $285.54 of $1,000.0029%
- Out-of-pocket maximum
- $777.03 of $2,000.0039%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2959091630
- Network
- In network
- Rendering NPI
- 8061926555
- Location
- Denver, CO · TIN 46-9380286
- 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 | 90471 | Immunization administration | — | 1 | 1 | $38.00 | $23.56 | $23.56 | $0.00 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $20.00 | $12.40 | $0.00 | $12.40 | Paid |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $284.00 | $176.08 | $0.00 | $176.08 | Paid |
| Totals | $342.00 | $212.04 | $23.56 | $188.48 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-614467
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002280 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-01: OPTIONS-PPO (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 7 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 Primary Care Associates (2959091630). | |
| 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 Primary Care Associates2026-01-01 13:09
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010580 | 2026-08-08 | Northgate Internal Medicine Associates | $361.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.