CLM-2026-007389
Evergreen Dermatology Clinic, Dermatology. Service 2026-05-29 at office (POS 11). Received 2026-06-13.
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
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 5878434799
- Location
- Tempe, AZ · TIN 66-7462916
- 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 | $178.56 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $191.00 | $118.42 | — | — | Review |
| 3 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1 | $171.00 | $106.02 | — | — | Review |
| Totals | $650.00 | $403.00 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- Patient account
- PA-886560
- 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 15 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-007388, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Dermatology Clinic (1642343457). | |
| 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: Evergreen Dermatology Clinic2026-05-29 17:30
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-13 04:45
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-13 08:41
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-007388, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007388 | 2026-05-29 | Sunrise Dermatology Clinic | $650.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.