Professional claim · CMS-1500 · EDI 837P
CLM-2026-004396
Valley Skin Care Associates, Dermatology. Service 2026-06-29 at office (POS 11). Received 2026-07-06.
Approved
Billed
$800.00
2 lines
Allowed
$496.00
contract rate applied
Plan pays
$456.00
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Eric Martin
- Member ID
- UHC-27656-65
- Date of birth
- 1956-08-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-429206
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4913
- Coverage period
- 2023-12-01 to present
- Deductible
- $739.21 of $1,000.0074%
- Out-of-pocket maximum
- $304.94 of $4,000.008%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 2987742436
- Network
- In network
- Rendering NPI
- 4045533146
- Location
- Miami, FL · TIN 36-7948934
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $579.00 | $358.98 | $40.00 | $318.98 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $221.00 | $137.02 | $0.00 | $137.02 | Paid |
| Totals | $800.00 | $496.00 | $40.00 | $456.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L57.0 Actinic keratosis
Claim header
- Patient account
- PA-261760
- 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-037432 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-29: NULL (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 7 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 Valley Skin Care Associates (2987742436). | |
| 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: Valley Skin Care Associates2026-06-29 14:10
Patient seen for dermatitis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$800.00
Plan discount
$304.00
contracted rate
Plan paid
$456.00
You may owe
$40.00
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-2026-004397 | 2026-06-29 | Sunrise Skin Care Associates | $800.00 | 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.