CLM-2026-034129
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-04 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Luis Simmons
- Member ID
- UHC-91105-47
- Date of birth
- 2003-04-13
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416291
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3140
- Coverage period
- 2024-07-01 to 2026-04-26
- Deductible
- $353.47 of $500.0071%
- Out-of-pocket maximum
- $408.79 of $1,500.0027%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 4475009450
- Location
- Tempe, AZ · TIN 82-7144175
- Authorisation / referral
- none / REF399971
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $182.00 | $112.84 | — | — | DeniedCO27 |
| Totals | $182.00 | $112.84 | — | — | ||||||
- 1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
- Patient account
- PA-850926
- 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-038242 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-04 is after coverage terminated on 2026-04-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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 Orthopedic Specialists (4479500462). | |
| 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 Orthopedic Specialists2026-08-04 09:22
Patient seen for unilateral primary osteoarthritis, left knee.
- SystemSystem: Claims system2026-08-15 05:32
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-15 17:13
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-04 is after coverage terminated on 2026-04-26.
Other claims for this member
Same resolved identity
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
Service after coverage termination.