Professional claim · CMS-1500 · EDI 837P
CLM-2026-014937
Evergreen Dermatology Clinic, Dermatology. Service 2026-04-23 at office (POS 11). Received 2026-05-13.
ApprovedOut of network
Billed
$657.00
2 lines
Allowed
$295.65
contract rate applied
Plan pays
$255.65
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
- Alexander Marquez
- Member ID
- UHC-84217-49
- Date of birth
- 1978-08-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426067
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7334
- Coverage period
- 2023-05-01 to present
- Deductible
- $491.98 of $3,500.0014%
- Out-of-pocket maximum
- $1,950.29 of $10,500.0019%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 2019479601
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $443.00 | $199.35 | $40.00 | $159.35 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1,2 | $214.00 | $96.30 | $0.00 | $96.30 | Paid |
| Totals | $657.00 | $295.65 | $40.00 | $255.65 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-895321
- 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-022090 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-23: UNKNOWN (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 20 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. |
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: Evergreen Dermatology Clinic2026-04-23 15:53
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$657.00
Plan discount
$361.35
out-of-network allowance
Plan paid
$255.65
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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005721 | 2026-06-30 | Meadow Physical Therapy | $224.00 | Approved |
| CLM-2026-027628 | 2026-06-21 | Mesa Internal Medicine Associates | $97.00 | 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.