Professional claim · CMS-1500 · EDI 837P
CLM-2026-013149
Lakeside Skin Care Associates, Dermatology. Service 2025-12-25 at office (POS 11). Received 2026-01-12.
Approved
Billed
$690.00
3 lines
Allowed
$427.80
contract rate applied
Plan pays
$377.80
approved
Member owes
$50.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jonathan Ferguson
- Member ID
- UHC-93124-89
- Date of birth
- 1945-06-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406874
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7832
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,016.44 of $3,500.0058%
- Out-of-pocket maximum
- $2,436.34 of $7,000.0035%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7845642215
- Network
- In network
- Rendering NPI
- 4642763674
- Location
- Miami, FL · TIN 41-5264398
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $192.00 | $119.04 | $50.00 | $69.04 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | 25 | 1 | 2 | $312.00 | $193.44 | $0.00 | $193.44 | Paid |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $186.00 | $115.32 | $0.00 | $115.32 | Paid |
| Totals | $690.00 | $427.80 | $50.00 | $377.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
Claim header
- Patient account
- PA-542314
- 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-003552 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: OPTIONS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 18 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 Lakeside Skin Care Associates (7845642215). | |
| 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: Lakeside Skin Care Associates2025-12-25 12:43
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$690.00
Plan discount
$262.20
contracted rate
Plan paid
$377.80
You may owe
$50.00
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-2026-023243 | 2026-02-27 | Valley Regional Medical Center | $135.00 | 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.