CLM-2026-001895
Meadow Dermatology Clinic, Dermatology. Service 2026-08-25 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Douglas Sandoval
- Member ID
- UHC-17618-84
- Date of birth
- 2006-06-15
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-406027
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9372
- Coverage period
- 2025-03-01 to 2026-05-14
- Deductible
- $1,941.91 of $2,500.0078%
- Out-of-pocket maximum
- $132.50 of $7,500.002%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9555011474
- Network
- In network
- Rendering NPI
- 8227510517
- Location
- Austin, TX · TIN 78-9849970
- 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 | $592.00 | $367.04 | — | — | DeniedCO27 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $292.00 | $181.04 | — | — | DeniedCO27 |
| Totals | $884.00 | $548.08 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-226441
- 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-012088 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-25 is after coverage terminated on 2026-05-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 23 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 Meadow Dermatology Clinic (9555011474). | |
| 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: Meadow Dermatology Clinic2026-08-25 09:17
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-17 04:58
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-17 12:11
Called the provider office; awaiting documentation.
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 2026-08-25 is after coverage terminated on 2026-05-14.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006580 | 2026-08-25 | Summit Family Practice | $389.00 | Denied |
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.