Professional claim · CMS-1500 · Provider portal
CLM-2026-010768
Mesa Dermatology Clinic, Dermatology. Service 2025-12-22 at office (POS 11). Received 2026-01-29.
Approved
Billed
$1,087.00
3 lines
Allowed
$673.94
contract rate applied
Plan pays
$623.94
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
- Patrick Sanders
- Member ID
- UHC-58486-46
- Date of birth
- 2005-09-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-429942
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8425
- Coverage period
- 2023-01-01 to present
- Deductible
- $662.51 of $1,500.0044%
- Out-of-pocket maximum
- $1,182.65 of $4,500.0026%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5272774592
- Network
- In network
- Rendering NPI
- 9707328891
- Location
- Houston, TX · TIN 54-8065466
- 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 | $214.00 | $132.68 | $50.00 | $82.68 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1,2 | $242.00 | $150.04 | $0.00 | $150.04 | Paid |
| 3 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | 25 | 1 | 2 | $631.00 | $391.22 | $0.00 | $391.22 | Paid |
| Totals | $1,087.00 | $673.94 | $50.00 | $623.94 | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
Claim header
- Patient account
- PA-917058
- 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-008595 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: CORE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 38 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 Mesa Dermatology Clinic (5272774592). | |
| 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: Mesa Dermatology Clinic2025-12-22 14:29
Patient seen for dermatitis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$1,087.00
Plan discount
$413.06
contracted rate
Plan paid
$623.94
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-2026-013960 | 2026-10-07 | Canyon Skin Care Associates | $650.00 | Denied |
| CLM-2026-013959 | 2026-10-07 | Canyon Skin Care Associates | $650.00 | Approved |
| CLM-2026-013732 | 2026-08-04 | Pinecrest Bone and Joint Center | $259.00 | Needs review |
| CLM-2026-013863 | 2026-06-15 | Canyon Skin Care Associates | $782.00 | 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.