Professional claim · CMS-1500 · EDI 837P
CLM-2026-029385
Evergreen Medical Group, Family Medicine. Service 2026-03-09 at office (POS 11). Received 2026-04-04.
Approved
Billed
$439.00
2 lines
Allowed
$272.18
contract rate applied
Plan pays
$252.18
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Roger White
- Member ID
- UHC-38078-45
- Date of birth
- 1948-08-05
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-407530
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5884
- Coverage period
- 2024-10-01 to present
- Deductible
- $325.96 of $500.0065%
- Out-of-pocket maximum
- $836.51 of $2,000.0042%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2175082280
- Network
- In network
- Rendering NPI
- 2604073421
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $209.00 | $129.58 | $20.00 | $109.58 | Paid |
| 2 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $230.00 | $142.60 | $0.00 | $142.60 | Paid |
| Totals | $439.00 | $272.18 | $20.00 | $252.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-503713
- 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-015238 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-09: SELECT-EPO (EPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 26 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Medical Group2026-03-09 14:55
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$439.00
Plan discount
$166.82
contracted rate
Plan paid
$252.18
You may owe
$20.00
copay, deductible and coinsurance
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-2026-021568 | 2026-06-08 | Mesa Family Practice | $207.00 | Approved |
| CLM-2026-003068 | 2026-05-26 | Desert Reference Lab | $171.00 | Denied |
| CLM-2026-003389 | 2026-02-20 | Canyon Internal Medicine Associates | $161.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.