Professional claim · CMS-1500 · EDI 837P
CLM-2026-007388
Sunrise Dermatology Clinic, Dermatology. Service 2026-05-29 at office (POS 11). Received 2026-06-07.
ApprovedOut of network
Billed
$650.00
3 lines
Allowed
$292.50
contract rate applied
Plan pays
$242.50
approved
Member owes
$50.00
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
- Debra Campbel
- Member ID
- UHC-83937-54
- Date of birth
- 1985-06-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427259
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3150
- Coverage period
- 2023-07-01 to present
- Deductible
- $187.45 of $500.0037%
- Out-of-pocket maximum
- $706.04 of $1,500.0047%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 5878434799
- Location
- Houston, TX · TIN 60-8775890
- 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 | $288.00 | $129.60 | $50.00 | $79.60 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $191.00 | $85.95 | $0.00 | $85.95 | Paid |
| 3 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1 | $171.00 | $76.95 | $0.00 | $76.95 | Paid |
| Totals | $650.00 | $292.50 | $50.00 | $242.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
Claim header
- Patient account
- PA-934996
- 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-021206 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-29: CHOICE-PLUS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 9 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Dermatology Clinic2026-05-29 12:59
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$650.00
Plan discount
$357.50
out-of-network allowance
Plan paid
$242.50
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007389 | 2026-05-29 | Evergreen Dermatology Clinic | $650.00 | 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.