CLM-2026-001753
Evergreen Dermatology Clinic, Dermatology. Service 2026-01-10 at office (POS 11). Received 2026-02-22.
Member
Resolved through the identity graph
- Member
- Diana Miills
- Member ID
- none on golden record
- Date of birth
- 1941-03-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410348
- Relationship
- Self, Austin, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 1206694188
- Location
- Tempe, AZ · TIN 66-7462916
- 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 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $252.00 | $156.24 | — | — | PendedN30 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | 59 | 1 | 1 | $196.00 | $121.52 | — | — | PendedN30 |
| Totals | $448.00 | $277.76 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- Patient account
- PA-928819
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015143 (verified, link confidence 0.99). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 43 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 Dermatology Clinic (1642343457). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Dermatology Clinic2026-01-10 18:14
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-02-22 05:54
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-22 10:51
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-928819.pdf18 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. 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-2026-009806 | 2026-09-16 | Northgate Medical Group | $279.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.