Professional claim · CMS-1500 · EDI 837P
CLM-2026-006523
Lakeside Dermatology Clinic, Dermatology. Service 2025-12-25 at office (POS 11). Received 2026-01-24.
Approved
Billed
$999.00
3 lines
Allowed
$619.38
contract rate applied
Plan pays
$579.38
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Barbara Oliver
- Member ID
- UHC-71536-77
- Date of birth
- 1976-07-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414364
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0891
- Coverage period
- 2025-01-01 to 2026-06-09
- Deductible
- $618.00 of $1,000.0062%
- Out-of-pocket maximum
- $1,163.37 of $4,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 9507623749
- Location
- Charlotte, NC · TIN 35-6038374
- 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 | $158.00 | $97.96 | $40.00 | $57.96 | Paid |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $525.00 | $325.50 | $0.00 | $325.50 | Paid |
| 3 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $316.00 | $195.92 | $0.00 | $195.92 | Paid |
| Totals | $999.00 | $619.38 | $40.00 | $579.38 | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-201884
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007321 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-25: MEDICARE-ADV-A (MA), effective 2025-01-01, terms 2026-06-09. | |
| Timely filing | Pass | Received 30 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 Lakeside Dermatology Clinic (6608515485). | |
| 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Dermatology Clinic2025-12-25 13:07
Patient seen for dermatitis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$999.00
Plan discount
$379.62
contracted rate
Plan paid
$579.38
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004476 | 2026-06-14 | Evergreen Rehabilitation Center | $142.00 | Denied |
| CLM-2026-016462 | 2026-03-03 | Lakeside Imaging Center | $1,880.00 | 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.