Professional claim · CMS-1500 · EDI 837P
CLM-2026-002709
Mesa Dermatology Clinic, Dermatology. Service 2026-03-22 at office (POS 11). Received 2026-05-04.
Billed
$683.00
2 lines
Allowed
$423.46
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- David Jacobs
- Member ID
- none on golden record
- Date of birth
- 1999-01-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426008
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-6270
- Coverage period
- 2022-02-01 to present
- Deductible
- $416.12 of $500.0083%
- Out-of-pocket maximum
- $349.74 of $1,000.0035%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 4131308528
- Location
- San Diego, CA · TIN 46-9736501
- Authorisation / referral
- none / REF404465
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 | $215.00 | $133.30 | — | — | PendedIDQ |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1,2 | $468.00 | $290.16 | — | — | PendedIDQ |
| Totals | $683.00 | $423.46 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
Claim header
- Patient account
- PA-897646
- 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 | Fail | IDQ | Member record is in open steward case CASE-001872; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-22: CORE-HMO (HMO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 Mesa Dermatology Clinic (5120662585). | |
| 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. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Dermatology Clinic2026-03-22 14:05
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001872; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-22: CORE-HMO (HMO), effective 2022-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002710 | 2026-03-22 | Mesa Dermatology Clinic | $683.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.