CLM-2026-012408
Evergreen Dermatology Clinic, Dermatology. Service 2026-04-24 at office (POS 11). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Sean Howell
- Member ID
- none on golden record
- Date of birth
- 1982-03-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-420535
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-9194
- Coverage period
- 2021-09-01 to present
- Deductible
- $651.06 of $1,000.0065%
- Out-of-pocket maximum
- $319.06 of $4,000.008%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 5277005604
- Location
- Mesa, AZ · TIN 16-2434239
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $246.00 | $110.70 | — | — | PendedIDQ |
| Totals | $246.00 | $110.70 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-818953
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001688; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-24: MEDICARE-ADV-B (MA), effective 2021-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 14 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Evergreen Dermatology Clinic2026-04-24 13:45
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001688; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-24: MEDICARE-ADV-B (MA), effective 2021-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.