CLM-2026-006820
Meadow Dermatology Clinic, Dermatology. Service 2026-04-06 at office (POS 11). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Jerry Walsh
- Member ID
- UHC-90013-29
- Date of birth
- 1980-03-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427540
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3204
- Coverage period
- 2023-04-01 to 2026-02-02
- Deductible
- $136.14 of $500.0027%
- Out-of-pocket maximum
- $132.52 of $2,000.007%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9555011474
- Network
- In network
- Rendering NPI
- 2083512469
- Location
- Austin, TX · TIN 78-9849970
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $228.00 | $141.36 | — | — | DeniedCO27 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $225.00 | $139.50 | — | — | DeniedCO27 |
| Totals | $453.00 | $280.86 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-688214
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029914 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-06 is after coverage terminated on 2026-02-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 Meadow Dermatology Clinic (9555011474). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Dermatology Clinic2026-04-06 17:37
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-09 03:53
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-06 is after coverage terminated on 2026-02-02.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.