Professional claim · CMS-1500 · EDI 837P
CLM-2026-006842
Valley Skin Care Associates, Dermatology. Service 2026-01-09 at office (POS 11). Received 2026-01-26.
Approved
Billed
$698.00
3 lines
Allowed
$432.76
contract rate applied
Plan pays
$392.76
approved
Member owes
$40.00
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
- Roy James
- Member ID
- UHC-07344-39
- Date of birth
- 2008-11-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431847
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7736
- Coverage period
- 2024-08-01 to present
- Deductible
- $992.01 of $1,500.0066%
- Out-of-pocket maximum
- $645.05 of $3,000.0022%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 2987742436
- Network
- In network
- Rendering NPI
- 2250930569
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $194.00 | $120.28 | $40.00 | $80.28 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1,2 | $269.00 | $166.78 | $0.00 | $166.78 | Paid |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $235.00 | $145.70 | $0.00 | $145.70 | Paid |
| Totals | $698.00 | $432.76 | $40.00 | $392.76 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L57.0 Actinic keratosis
Claim header
- Patient account
- PA-316926
- 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-007895 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-09: CORE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Pass | Received 17 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 Associates2026-01-09 17:53
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$698.00
Plan discount
$265.24
contracted rate
Plan paid
$392.76
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-2026-032001 | 2025-11-15 | Desert Reference Lab | $81.00 | Denied |
| CLM-2026-006843 | 2026-01-09 | Valley Skin Care Associates | $698.00 | 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.