Professional claim · CMS-1500 · EDI 837P
CLM-2026-016089
Northgate Dermatology Clinic, Dermatology. Service 2026-07-16 at office (POS 11). Received 2026-08-20.
Denied
Billed
$636.00
3 lines
Allowed
$394.32
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Maria Rice
- Member ID
- UHC-48373-74
- Date of birth
- 1976-04-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-409238
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-5819
- Coverage period
- 2021-11-01 to 2026-02-12
- Deductible
- $587.19 of $1,000.0059%
- Out-of-pocket maximum
- $345.30 of $3,000.0012%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 5207238978
- Location
- Mesa, AZ · TIN 98-6879674
- 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 | $197.00 | $122.14 | — | — | DeniedCO27 |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $252.00 | $156.24 | — | — | DeniedCO27 |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $187.00 | $115.94 | — | — | DeniedCO27 |
| Totals | $636.00 | $394.32 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
Claim header
- Patient account
- PA-876730
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011814 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-16 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 Northgate Dermatology Clinic (7707045416). | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Dermatology Clinic2026-07-16 09:12
Patient seen for psoriasis vulgaris.
- SystemSystem: Claims system2026-08-20 01:47
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-16 is after coverage terminated on 2026-02-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005678 | 2025-12-29 | Riverside Primary Care Associates | $534.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied 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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.