Professional claim · CMS-1500 · EDI 837P
CLM-2026-032666
Evergreen Family Practice, Family Medicine. Service 2026-04-27 at office (POS 11). Received 2026-05-21.
Denied
Billed
$373.00
3 lines
Allowed
$231.26
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Amber Ruiz
- Member ID
- UHC-70601-68
- Date of birth
- 1947-11-07
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-432290
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2022-03-01 to 2026-02-13
- Deductible
- $333.44 of $500.0067%
- Out-of-pocket maximum
- $48.41 of $1,000.005%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9423912895
- Network
- In network
- Rendering NPI
- 1331764740
- Location
- Austin, TX · TIN 10-8497097
- 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 | 59 | 1 | 1 | $319.00 | $197.78 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | 59 | 1 | 1,2 | $37.00 | $22.94 | — | — | DeniedCO27 |
| 3 | 36415 | Venipuncture | — | 1 | 1,2 | $17.00 | $10.54 | — | — | DeniedCO27 |
| Totals | $373.00 | $231.26 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-542179
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027381 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-27 is after coverage terminated on 2026-02-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 (9423912895). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Family Practice2026-04-27 13:50
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-05-21 03:56
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-27 is after coverage terminated on 2026-02-13. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030240 | 2026-04-20 | Sunrise Imaging Center | $218.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.