Professional claim · CMS-1500 · EDI 837P
CLM-2026-012263
Sunrise Skin Care Associates, Dermatology. Service 2026-04-14 at office (POS 11). Received 2026-05-06.
Approved
Billed
$408.00
2 lines
Allowed
$252.96
contract rate applied
Plan pays
$177.96
approved
Member owes
$75.00
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
- Charlotte Jones
- Member ID
- UHC-60711-64
- Date of birth
- 1996-09-22
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-402107
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3227
- Coverage period
- 2023-03-01 to present
- Deductible
- $554.40 of $2,500.0022%
- Out-of-pocket maximum
- $0.60 of $5,000.000%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 1951970627
- Network
- In network
- Rendering NPI
- 4143062667
- Location
- Dallas, TX · TIN 80-3585708
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $236.00 | $146.32 | $75.00 | $71.32 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $172.00 | $106.64 | $0.00 | $106.64 | Paid |
| Totals | $408.00 | $252.96 | $75.00 | $177.96 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
Claim header
- Patient account
- PA-324100
- 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-029354 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-14: OPTIONS-PPO (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 22 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 Sunrise Skin Care Associates (1951970627). | |
| 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: Sunrise Skin Care Associates2026-04-14 13:05
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$408.00
Plan discount
$155.04
contracted rate
Plan paid
$177.96
You may owe
$75.00
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
No other claims.
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.