Professional claim · CMS-1500 · Paper
CLM-2026-001720
Canyon Skin Care Associates, Dermatology. Service 2026-03-29 at office (POS 11). Received 2026-04-25.
Approved
Billed
$406.00
2 lines
Allowed
$251.72
contract rate applied
Plan pays
$201.72
approved
Member owes
$50.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Brian Cole
- Member ID
- UHC-86309-43
- Date of birth
- 1959-09-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400634
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6276
- Coverage period
- 2024-09-01 to present
- Deductible
- $201.81 of $1,000.0020%
- Out-of-pocket maximum
- $931.45 of $2,000.0047%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 4373091113
- Location
- Nashville, TN · TIN 35-2130614
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $233.00 | $144.46 | $50.00 | $94.46 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $173.00 | $107.26 | $0.00 | $107.26 | Paid |
| Totals | $406.00 | $251.72 | $50.00 | $201.72 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
Claim header
- Patient account
- PA-669992
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027696 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-29: OPTIONS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 27 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 Canyon Skin Care Associates (5664814501). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Skin Care Associates2026-03-29 11:08
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$406.00
Plan discount
$154.28
contracted rate
Plan paid
$201.72
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
No other claims.
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.