CLM-2026-029874
Evergreen Family Practice, Family Medicine. Service 2026-08-11 at office (POS 11). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Hannah Watson
- Member ID
- UHC-44586-69
- Date of birth
- 1995-07-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410718
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1669
- Coverage period
- 2021-03-01 to present
- Deductible
- $127.20 of $500.0025%
- Out-of-pocket maximum
- $728.60 of $1,500.0049%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 1600303576
- Network
- In network
- Rendering NPI
- 3951977701
- Location
- Los Angeles, CA · TIN 10-4370039
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $339.00 | $210.18 | — | — | DeniedCO18 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $220.00 | $136.40 | — | — | DeniedCO18 |
| Totals | $559.00 | $346.58 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-481143
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031363 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-11: CHOICE-PLUS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-029873: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Family Practice (1600303576). | |
| 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 Family Practice2026-08-11 09:59
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-29 04:50
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-029873: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029873 | 2026-08-11 | Evergreen Family Practice | $559.00 | Approved |
| CLM-2026-012840 | 2026-05-13 | Riverside Bone and Joint Center | $10,660.00 | Approved |
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
Exact duplicate of an earlier submission.