Professional claim · CMS-1500 · EDI 837P
CLM-2026-003268
Sunrise Dermatology Clinic, Dermatology. Service 2026-02-09 at office (POS 11). Received 2026-03-21.
Approved
Billed
$432.00
2 lines
Allowed
$267.84
contract rate applied
Plan pays
$217.84
approved
Member owes
$50.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Christian Wheeler
- Member ID
- UHC-84072-99
- Date of birth
- 1976-08-08
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-432286
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8066
- Coverage period
- 2024-11-01 to present
- Deductible
- $408.41 of $1,500.0027%
- Out-of-pocket maximum
- $1,455.68 of $3,000.0049%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9318370597
- Network
- In network
- Rendering NPI
- 6431839359
- Location
- Los Angeles, CA · TIN 15-7693212
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $173.00 | $107.26 | $50.00 | $57.26 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | 25 | 1 | 1 | $259.00 | $160.58 | $0.00 | $160.58 | Paid |
| Totals | $432.00 | $267.84 | $50.00 | $217.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L57.0 Actinic keratosis
Claim header
- Patient account
- PA-287149
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-021093 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-09: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 40 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 Sunrise Dermatology Clinic (9318370597). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Dermatology Clinic2026-02-09 09:54
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$432.00
Plan discount
$164.16
contracted rate
Plan paid
$217.84
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031651 | 2026-06-20 | Meadow Family Practice | $3,066.00 | Needs review |
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.