Professional claim · CMS-1500 · Provider portal
CLM-2026-007856
Evergreen Dermatology Clinic, Dermatology. Service 2026-01-30 at office (POS 11). Received 2026-03-15.
ApprovedOut of network
Billed
$937.00
3 lines
Allowed
$421.65
contract rate applied
Plan pays
$371.65
approved
Member owes
$50.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Sofia Wallace
- Member ID
- UHC-07269-10
- Date of birth
- 1989-07-10
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-419363
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8516
- Coverage period
- 2023-04-01 to present
- Deductible
- $942.26 of $1,500.0063%
- Out-of-pocket maximum
- $354.86 of $4,500.008%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 7904200970
- Location
- Mesa, AZ · TIN 16-2434239
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $577.00 | $259.65 | $50.00 | $209.65 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 2 | $189.00 | $85.05 | $0.00 | $85.05 | Paid |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $171.00 | $76.95 | $0.00 | $76.95 | Paid |
| Totals | $937.00 | $421.65 | $50.00 | $371.65 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
Claim header
- Patient account
- PA-701954
- 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-019011 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-30: MEDICARE-ADV-A (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 44 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: Evergreen Dermatology Clinic2026-01-30 13:51
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$937.00
Plan discount
$515.35
out-of-network allowance
Plan paid
$371.65
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-2026-026263 | 2026-09-01 | Desert Primary Care Associates | $227.00 | Approved |
| CLM-2026-029446 | 2026-09-15 | Heritage Orthopedic Specialists | $3,040.00 | Needs review |
| CLM-2026-019432 | 2026-02-17 | Heritage Clinical Laboratories | $52.00 | Approved |
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.