CLM-2026-013224
Evergreen Dermatology Clinic, Dermatology. Service 2026-05-29 at office (POS 11). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Benjamin Yang
- Member ID
- UHC-59355-41
- Date of birth
- 1939-10-25
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-407058
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1656
- Coverage period
- 2023-02-01 to present
- Deductible
- $167.60 of $1,000.0017%
- Out-of-pocket maximum
- $816.88 of $2,000.0041%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 5702607503
- 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 | $224.00 | $100.80 | — | — | DeniedCO204 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $207.00 | $93.15 | — | — | DeniedCO204 |
| 3 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1,2 | $653.00 | $293.85 | — | — | DeniedCO204 |
| Totals | $1,084.00 | $487.80 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-633230
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035297 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-29: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 19 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 | Fail | CO204 | Billing provider 5921287756 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Clinic2026-05-29 11:57
Follow-up for melanocytic nevi of trunk. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-17 04:59
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5921287756 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.