CLM-2026-029062
Evergreen Primary Care Associates, Family Medicine. Service 2026-04-05 at office (POS 11). Received 2026-04-29.
Member
Resolved through the identity graph
- Member
- Emma Clark
- Member ID
- UHC-74207-75
- Date of birth
- 2005-11-07
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427907
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9080
- Coverage period
- 2022-01-01 to present
- Deductible
- $346.24 of $1,000.0035%
- Out-of-pocket maximum
- $854.34 of $2,000.0043%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- 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
- 7563304394
- 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 | 36415 | Venipuncture | — | 1 | 1 | $23.00 | $14.26 | $14.26 | $0.00 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $157.00 | $97.34 | $0.00 | $97.34 | Paid |
| Totals | $180.00 | $111.60 | $14.26 | $97.34 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-240801
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004855 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-05: OPTIONS-PPO (PPO), effective 2022-01-01. | |
| 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 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 Associates2026-04-05 18:26
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019976 | 2025-12-14 | Evergreen Family Practice | $512.00 | 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.