CLM-2026-010544
Meadow Skin Care Associates, Dermatology. Service 2025-11-05 at office (POS 11). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Logan Jensen
- Member ID
- UHC-93744-90
- Date of birth
- 1965-06-18
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-414249
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2005
- Coverage period
- 2022-12-01 to present
- Deductible
- $690.41 of $2,500.0028%
- Out-of-pocket maximum
- $2,526.81 of $7,500.0034%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5570109764
- Network
- In network
- Rendering NPI
- 1901845416
- Location
- Miami, FL · TIN 98-6447059
- 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 | $480.00 | $297.60 | — | — | DeniedCO29 |
| Totals | $480.00 | $297.60 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-835849
- 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-020385 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-11-05: SELECT-EPO (EPO), effective 2022-12-01. | |
| Timely filing | Fail | CO29 | Received 133 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Skin Care Associates (5570109764). | |
| 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: Meadow Skin Care Associates2025-11-05 17:26
Patient seen for actinic keratosis.
- SystemSystem: Claims system2026-03-18 05:42
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-18 10:17
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 133 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018758 | 2026-10-02 | Desert Rehabilitation Center | $457.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.