Professional claim · CMS-1500 · EDI 837P
CLM-2026-005240
Sunrise Skin Care Associates, Dermatology. Service 2026-09-05 at office (POS 11). Received 2026-10-04.
Approved
Billed
$693.00
2 lines
Allowed
$429.66
contract rate applied
Plan pays
$369.66
approved
Member owes
$60.00
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
- George West
- Member ID
- UHC-85557-32
- Date of birth
- 1993-12-28
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-427114
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1457
- Coverage period
- 2022-02-01 to present
- Deductible
- $760.03 of $2,500.0030%
- Out-of-pocket maximum
- $186.59 of $10,000.002%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 1951970627
- Network
- In network
- Rendering NPI
- 3897750618
- Location
- Dallas, TX · TIN 80-3585708
- Authorisation / referral
- none / REF891536
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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $306.00 | $189.72 | $60.00 | $129.72 | Paid |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $387.00 | $239.94 | $0.00 | $239.94 | Paid |
| Totals | $693.00 | $429.66 | $60.00 | $369.66 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
Claim header
- Patient account
- PA-272048
- 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-015470 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-05: NAVIGATE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 29 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 Skin Care Associates (1951970627). | |
| 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 Skin Care Associates2026-09-05 17:14
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$693.00
Plan discount
$263.34
contracted rate
Plan paid
$369.66
You may owe
$60.00
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
No other claims.
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.