CLM-2026-030726
Evergreen Family Practice, Family Medicine. Service 2026-06-29 at office (POS 11). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Brian Allen
- Member ID
- none on golden record
- Date of birth
- 1951-05-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-403396
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5857456904
- Network
- In network
- Rendering NPI
- 2799346186
- Location
- Austin, TX · TIN 44-5200426
- 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 | $239.00 | $148.18 | — | — | PendedN30 |
| 2 | 90471 | Immunization administration | — | 1 | 2 | $32.00 | $19.84 | — | — | PendedN30 |
| Totals | $271.00 | $168.02 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-948280
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020437 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-030725, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Family Practice (5857456904). | |
| 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 Practice2026-06-29 09:23
Patient seen for acute upper respiratory infection, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-23 02:00
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-23 15:36
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Same member, date of service and procedures as CLM-2026-030725, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030725 | 2026-06-29 | Evergreen Family Practice | $271.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.