Professional claim · CMS-1500 · EDI 837P
CLM-2026-002223
Mesa Dermatology Clinic, Dermatology. Service 2026-05-25 at office (POS 11). Received 2026-06-29.
Approved
Billed
$663.00
3 lines
Allowed
$411.06
contract rate applied
Plan pays
$361.06
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
- Billy Collins
- Member ID
- UHC-88822-54
- Date of birth
- 1941-06-06
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-422165
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1665
- Coverage period
- 2022-04-01 to present
- Deductible
- $427.94 of $500.0086%
- Out-of-pocket maximum
- $84.82 of $1,000.008%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6249986509
- Network
- In network
- Rendering NPI
- 4859594432
- Location
- Nashville, TN · TIN 73-5403948
- 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 | — | 1 | 1 | $293.00 | $181.66 | $50.00 | $131.66 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $166.00 | $102.92 | $0.00 | $102.92 | Paid |
| 3 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1 | $204.00 | $126.48 | $0.00 | $126.48 | Paid |
| Totals | $663.00 | $411.06 | $50.00 | $361.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-403392
- 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-000038 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-25: MEDICARE-ADV-A (MA), effective 2022-04-01. | |
| Timely filing | Pass | Received 35 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 Mesa Dermatology Clinic (6249986509). | |
| 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: Mesa Dermatology Clinic2026-05-25 12:33
Patient seen for melanocytic nevi of trunk.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$663.00
Plan discount
$251.94
contracted rate
Plan paid
$361.06
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.