Professional claim · CMS-1500 · EDI 837P
CLM-2026-012919
Meadow Dermatology Clinic, Dermatology. Service 2026-08-18 at office (POS 11). Received 2026-08-30.
Approved
Billed
$706.00
2 lines
Allowed
$437.72
contract rate applied
Plan pays
$397.72
approved
Member owes
$40.00
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
- Lawrence Flores
- Member ID
- UHC-58157-26
- Date of birth
- 2008-06-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427256
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8223
- Coverage period
- 2022-12-01 to present
- Deductible
- $247.42 of $500.0049%
- Out-of-pocket maximum
- $493.02 of $1,500.0033%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9555011474
- Network
- In network
- Rendering NPI
- 4899685307
- Location
- Austin, TX · TIN 78-9849970
- 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 | $483.00 | $299.46 | $40.00 | $259.46 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $223.00 | $138.26 | $0.00 | $138.26 | Paid |
| Totals | $706.00 | $437.72 | $40.00 | $397.72 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
Claim header
- Patient account
- PA-504685
- 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-015236 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-18: MEDICARE-ADV-A (MA), effective 2022-12-01. | |
| Timely filing | Pass | Received 12 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 Meadow Dermatology Clinic (9555011474). | |
| 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: Meadow Dermatology Clinic2026-08-18 17:18
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$706.00
Plan discount
$268.28
contracted rate
Plan paid
$397.72
You may owe
$40.00
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-2026-011573 | 2026-03-13 | Sunrise Imaging Center | $1,852.00 | Approved |
| CLM-2026-019680 | 2026-02-07 | Canyon Diagnostic Imaging | $2,432.00 | 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.