Professional claim · CMS-1500 · EDI 837P
CLM-2026-011616
Northgate Dermatology Clinic, Dermatology. Service 2026-02-25 at office (POS 11). Received 2026-03-06.
Approved
Billed
$996.00
3 lines
Allowed
$617.52
contract rate applied
Plan pays
$577.52
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Larry Reed
- Member ID
- UHC-86408-56
- Date of birth
- 1939-03-11
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-423823
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-4499
- Coverage period
- 2025-04-01 to present
- Deductible
- $419.26 of $1,000.0042%
- Out-of-pocket maximum
- $235.30 of $3,000.008%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 1490961301
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $504.00 | $312.48 | $40.00 | $272.48 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | 25 | 1 | 2 | $216.00 | $133.92 | $0.00 | $133.92 | Paid |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 2 | $276.00 | $171.12 | $0.00 | $171.12 | Paid |
| Totals | $996.00 | $617.52 | $40.00 | $577.52 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L57.0 Actinic keratosis
Claim header
- Patient account
- PA-488671
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017870 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-25: UNKNOWN (PPO), effective 2025-04-01. | |
| 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 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Dermatology Clinic2026-02-25 10:38
Patient seen for melanocytic nevi of trunk.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$996.00
Plan discount
$378.48
contracted rate
Plan paid
$577.52
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010331 | 2026-08-22 | Meadow Heart Institute | $241.00 | 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.