Claims workbench/CLM-2026-004282
Professional claim · CMS-1500 · EDI 837P

CLM-2026-004282

Unity Dermatology Clinic, Dermatology. Service 2026-01-06 at office (POS 11). Received 2026-01-28.

Denied
Billed
$491.00
1 line
Allowed
$304.42
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Deborah Smith
Member ID
UHC-06521-05
Date of birth
1955-02-11
Identity
Verified4 records, confidence 0.97
Claim record
CLMCLM-410405
Relationship
Self, Plano, TX

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-6888
Coverage period
2022-02-01 to 2026-03-19
Deductible
$828.50 of $1,500.0055%
Out-of-pocket maximum
$1,177.11 of $4,500.0026%
Copays
office $30.00, specialist $60.00, emergency $350.00
Physical therapy visits
11 of 20 used

Provider

Billing and rendering

Billing provider
Unity Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
1114969961
Network
In network
Rendering NPI
1382695595
Location
Tampa, FL · TIN 40-1762241
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
111403Excision benign lesion, trunk, 2.1-3.0 cm—11$491.00$304.42——DeniedCO18
Totals$491.00$304.42——
Diagnoses (ICD-10-CM)
  • 1. L57.0 Actinic keratosisprincipal
Claim header
Patient account
PA-802461
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

CheckResultCodeDetail
Member identityPassAttached to MBR-003042 (verified, link confidence 0.97).
EligibilityPassActive on 2026-01-06: OPTIONS-PPO (PPO), effective 2022-02-01, terms 2026-03-19.
Timely filingPassReceived 22 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-004281: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Dermatology Clinic (1114969961).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Clinic2026-01-06 12:20

    Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.

  • SystemSystem: Claims system2026-01-28 01:34

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Duplicate check: Exact duplicate of CLM-2026-004281: same member, date of service, procedures and billing provider.
  2. AI recommendation recordedcli_adjudicator2026-10-21 13:39 · 7e643b27

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0051072026-04-22Desert Reference Lab$124.00Denied
CLM-2026-0042812026-01-06Unity Dermatology Clinic$491.00Approved

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity