CLM-2026-032348
Evergreen Family Practice, Family Medicine. Service 2026-06-13 at office (POS 11). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Debbie Ortega
- Member ID
- UHC-05686-65
- Date of birth
- 1966-09-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428977
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6466
- Coverage period
- 2024-12-01 to present
- Deductible
- $143.35 of $500.0029%
- Out-of-pocket maximum
- $22.74 of $1,000.002%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 5857456904
- Network
- In network
- Rendering NPI
- 3243808128
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $284.00 | $176.08 | $30.00 | $146.08 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $141.00 | $87.42 | $0.00 | $87.42 | Paid |
| Totals | $425.00 | $263.50 | $30.00 | $233.50 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-541715
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036249 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-13: SELECT-EPO (EPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 12 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 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 Practice2026-06-13 12:51
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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.