Professional claim · CMS-1500 · EDI 837P
CLM-2026-003319
Unity Dermatology Clinic, Dermatology. Service 2026-10-06 at office (POS 11). Received 2026-10-18.
Denied
Billed
$760.00
2 lines
Allowed
$471.20
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Keith Vazquez
- Member ID
- UHC-01356-46
- Date of birth
- 1965-05-23
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-403710
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1196
- Coverage period
- 2024-07-01 to 2026-07-01
- Deductible
- $248.62 of $500.0050%
- Out-of-pocket maximum
- $587.70 of $2,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1114969961
- Network
- In network
- Rendering NPI
- 5418160136
- Location
- Tampa, FL · TIN 40-1762241
- 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 | $226.00 | $140.12 | — | — | DeniedCO27 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $534.00 | $331.08 | — | — | DeniedCO27 |
| Totals | $760.00 | $471.20 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L40.0 Psoriasis vulgaris
Claim header
- Patient account
- PA-898193
- 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-012139 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-06 is after coverage terminated on 2026-07-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Unity Dermatology Clinic (1114969961). | |
| 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: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Dermatology Clinic2026-10-06 12:54
Follow-up for melanocytic nevi of trunk. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-18 00:40
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-06 is after coverage terminated on 2026-07-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034579 | 2026-09-09 | Lakeside Medical Group | $508.00 | Denied |
| CLM-2026-009389 | 2026-05-20 | Lakeside Medical Group | $198.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.