Professional claim · CMS-1500 · EDI 837P
CLM-2026-030317
Evergreen Medical Group, Family Medicine. Service 2026-08-07 at office (POS 11). Received 2026-08-21.
Approved
Billed
$268.00
1 line
Allowed
$166.16
contract rate applied
Plan pays
$136.16
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Mary Ford
- Member ID
- none on golden record
- Date of birth
- 1986-07-04
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-426365
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group UNKNOWN
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,247.21 of $2,500.0050%
- Out-of-pocket maximum
- $3,816.53 of $10,000.0038%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3925619678
- Network
- In network
- Rendering NPI
- 5430619689
- Location
- Phoenix, AZ · TIN 51-3095998
- 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 | $268.00 | $166.16 | $30.00 | $136.16 | Paid |
| Totals | $268.00 | $166.16 | $30.00 | $136.16 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- 3. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-215515
- 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-042104 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-08-07: NAVIGATE-HMO (HMO), effective 2023-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 (3925619678). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Medical Group2026-08-07 18:01
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$268.00
Plan discount
$101.84
contracted rate
Plan paid
$136.16
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Eligibility: Active on 2026-08-07: NAVIGATE-HMO (HMO), effective 2023-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002868 | 2026-07-30 | Evergreen Primary Care Associates | $287.00 | Approved |
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.