Professional claim · CMS-1500 · EDI 837P
CLM-2026-003820
Unity Dermatology Clinic, Dermatology. Service 2026-04-19 at office (POS 11). Received 2026-04-23.
Approved
Billed
$151.00
1 line
Allowed
$93.62
contract rate applied
Plan pays
$18.62
approved
Member owes
$75.00
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
- Russell Guerrero
- Member ID
- UHC-89202-61
- Date of birth
- 1975-09-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417248
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5160
- Coverage period
- 2022-09-01 to 2026-08-28
- Deductible
- $1,970.91 of $2,500.0079%
- Out-of-pocket maximum
- $1,359.81 of $10,000.0014%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1114969961
- Network
- In network
- Rendering NPI
- 9662860516
- 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 | $151.00 | $93.62 | $75.00 | $18.62 | Paid |
| Totals | $151.00 | $93.62 | $75.00 | $18.62 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-351354
- 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-027376 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-19: MEDICARE-ADV-A (MA), effective 2022-09-01, terms 2026-08-28. | |
| Timely filing | Pass | Received 4 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Dermatology Clinic2026-04-19 12:50
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
$151.00
Plan discount
$57.38
contracted rate
Plan paid
$18.62
You may owe
$75.00
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-2026-015770 | 2026-05-14 | Riverside Orthopedic Specialists | $219.00 | 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.