Professional claim · CMS-1500 · EDI 837P
CLM-2026-002624
Evergreen Dermatology Clinic, Dermatology. Service 2025-12-13 at office (POS 11). Received 2026-01-11.
Approved
Billed
$368.00
2 lines
Allowed
$228.16
contract rate applied
Plan pays
$178.16
approved
Member owes
$50.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Judy Walker
- Member ID
- UHC-62518-63
- Date of birth
- 1964-12-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-424543
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2954
- Coverage period
- 2024-07-01 to present
- Deductible
- $55.23 of $3,500.002%
- Out-of-pocket maximum
- $1,740.21 of $14,000.0012%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 9062813883
- Location
- Tempe, AZ · TIN 66-7462916
- Authorisation / referral
- none / REF699180
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 | $214.00 | $132.68 | $50.00 | $82.68 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 1 | $154.00 | $95.48 | $0.00 | $95.48 | Paid |
| Totals | $368.00 | $228.16 | $50.00 | $178.16 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-880699
- 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-003400 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-13: NAVIGATE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 29 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) | 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: Evergreen Dermatology Clinic2025-12-13 11:42
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
$368.00
Plan discount
$139.84
contracted rate
Plan paid
$178.16
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.