Professional claim · CMS-1500 · EDI 837P
CLM-2026-000966
Valley Skin Care Associates, Dermatology. Service 2025-12-30 at office (POS 11). Received 2026-01-10.
ApprovedOut of network
Billed
$419.00
1 line
Allowed
$188.55
contract rate applied
Plan pays
$138.55
approved
Member owes
$50.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Natalie Williams
- Member ID
- UHC-27759-35
- Date of birth
- 1960-03-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-401137
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- - PPO group N/A
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,116.92 of $3,500.0032%
- Out-of-pocket maximum
- $2,408.71 of $7,000.0034%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 1196472173
- Location
- Scottsdale, AZ · TIN 26-4772029
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $419.00 | $188.55 | $50.00 | $138.55 | Paid |
| Totals | $419.00 | $188.55 | $50.00 | $138.55 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
Claim header
- Patient account
- PA-179346
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002986 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-30: - (PPO), effective 2025-10-01. | |
| 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Skin Care Associates2025-12-30 09:32
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$419.00
Plan discount
$230.45
out-of-network allowance
Plan paid
$138.55
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012008 | 2026-08-08 | Northgate Reference Lab | $216.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.