Professional claim · CMS-1500 · Paper
CLM-2026-009549
Lakeside Skin Care Associates, Dermatology. Service 2026-10-03 at office (POS 11). Received 2026-10-12.
Approved
Billed
$162.00
1 line
Allowed
$100.44
contract rate applied
Plan pays
$50.44
approved
Member owes
$50.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Christine Wallace
- Member ID
- UHC-56875-41
- Date of birth
- 1962-08-25
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-431707
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1427
- Coverage period
- 2022-04-01 to present
- Deductible
- $700.24 of $1,000.0070%
- Out-of-pocket maximum
- $214.14 of $4,000.005%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7921872736
- Network
- In network
- Rendering NPI
- 1903402554
- Location
- Tempe, AZ · TIN 98-6599721
- 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 | $162.00 | $100.44 | $50.00 | $50.44 | Paid |
| Totals | $162.00 | $100.44 | $50.00 | $50.44 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L57.0 Actinic keratosis
Claim header
- Patient account
- PA-823835
- 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-000404 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-10-03: OPTIONS-PPO (PPO), effective 2022-04-01. | |
| 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 | Pass | In-network provider Lakeside Skin Care Associates (7921872736). | |
| 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: Lakeside Skin Care Associates2026-10-03 09:14
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$162.00
Plan discount
$61.56
contracted rate
Plan paid
$50.44
You may owe
$50.00
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-2026-004105 | 2026-09-09 | Lakeside Bone and Joint Center | $35,290.00 | Needs review |
| CLM-2026-019010 | 2026-01-24 | Canyon Reference Lab | $38.00 | Denied |
| CLM-2026-019009 | 2026-01-24 | Canyon Reference Lab | $38.00 | Approved |
| CLM-2026-003011 | 2025-12-05 | Meadow Physical Therapy | $277.00 | 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.