Professional claim · CMS-1500 · Provider portal
CLM-2026-008898
Northgate Dermatology Clinic, Dermatology. Service 2026-04-02 at office (POS 11). Received 2026-04-07.
Approved
Billed
$282.00
1 line
Allowed
$174.84
contract rate applied
Plan pays
$134.84
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Alice Gordon
- Member ID
- UHC-20139-14
- Date of birth
- 1961-02-17
- Identity
- Verified7 records, confidence 0.98
- Claim record
- CLMCLM-419220
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2437
- Coverage period
- 2025-07-01 to present
- Deductible
- $222.38 of $500.0044%
- Out-of-pocket maximum
- $455.09 of $1,000.0046%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 6600217965
- Location
- Mesa, AZ · TIN 98-6879674
- 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 | $282.00 | $174.84 | $40.00 | $134.84 | Paid |
| Totals | $282.00 | $174.84 | $40.00 | $134.84 | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-540288
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018449 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-04-02: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 5 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 Northgate Dermatology Clinic (7707045416). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Dermatology Clinic2026-04-02 17:34
Patient seen for dermatitis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$282.00
Plan discount
$107.16
contracted rate
Plan paid
$134.84
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008899 | 2026-04-02 | Mesa Dermatology Clinic | $282.00 | Needs review |
| CLM-2026-032741 | 2026-03-26 | Cornerstone Internal Medicine Associates | $47.00 | Approved |
| CLM-2026-019091 | 2026-02-20 | Mesa Reference Lab | $207.00 | 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.