CLM-2026-034114
Evergreen Internal Medicine Associates, Internal Medicine. Service 2026-03-25 at office (POS 11). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Karen Foster
- Member ID
- UHC-09837-69
- Date of birth
- 1992-04-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421467
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1795
- Coverage period
- 2024-08-01 to present
- Deductible
- $378.52 of $3,500.0011%
- Out-of-pocket maximum
- $6,116.15 of $14,000.0044%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8561588111
- Network
- In network
- Rendering NPI
- 2808168803
- Location
- Nashville, TN · TIN 40-5460828
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $119.00 | $73.78 | — | — | DeniedCO18 |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $341.00 | $211.42 | — | — | DeniedCO18 |
| Totals | $460.00 | $285.20 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-125610
- 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-000741 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-25: SELECT-EPO (EPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-034113: 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 Internal Medicine Associates (8561588111). | |
| 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 Internal Medicine Associates2026-03-25 16:14
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-10 04:00
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-2026-034113: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021328 | 2026-07-30 | Unity Dermatology Clinic | $781.00 | Needs review |
| CLM-2026-015302 | 2026-07-29 | Meadow Family Practice | $520.00 | Approved |
| CLM-2026-034113 | 2026-03-25 | Evergreen Internal Medicine Associates | $460.00 | 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.