Professional claim · CMS-1500 · EDI 837P
CLM-2026-012460
Valley Skin Care Associates, Dermatology. Service 2026-07-26 at office (POS 11). Received 2026-08-08.
Needs reviewOut of network
Billed
$520.00
2 lines
Allowed
$234.00
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Review
CO16
Decided by
Nobody yet
open
Member
Resolved through the identity graph
- Member
- Lucia Rios
- Member ID
- UHC-92720-51
- Date of birth
- 1939-04-02
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-428691
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8351
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,624.17 of $2,500.0065%
- Out-of-pocket maximum
- $1,945.07 of $7,500.0026%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 9542995441
- Location
- Scottsdale, AZ · TIN 26-4772029
- 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 | $291.00 | $130.95 | — | — | Review |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $229.00 | $103.05 | — | — | Review |
| Totals | $520.00 | $234.00 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
Claim header
- Patient account
- PA-733087
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006680 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-26: MEDICARE-ADV-B (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 13 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 | Review | CO16 | Documentation incomplete: “Patient seen for psoriasis vulgaris. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Skin Care Associates2026-07-26 13:52
Patient seen for psoriasis vulgaris. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-08 03:35
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Patient seen for psoriasis vulgaris. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000769 | 2026-08-03 | Mesa Medical Group | $442.00 | Approved |
| CLM-2026-005989 | 2026-06-15 | Canyon Clinical Laboratories | $59.00 | Approved |
| CLM-2026-031672 | 2026-04-12 | Mesa Family Practice | $278.00 | Denied |
| CLM-2026-031671 | 2026-04-12 | Mesa Family Practice | $278.00 | Approved |
| CLM-2026-007108 | 2026-02-26 | Mesa Clinical Laboratories | $128.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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
PendedCO16scenario: Missing info
Development letter outstanding.