Claims workbench/CLM-2026-018784
Professional claim · CMS-1500 · Provider portal

CLM-2026-018784

Evergreen Dermatology Clinic, Dermatology. Service 2026-08-23 at office (POS 11). Received 2026-09-09.

Denied
Billed
$614.00
1 line
Allowed
$380.68
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
James Mejia
Member ID
UHC-92828-80
Date of birth
1976-04-10
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-417593
Relationship
Self, Columbus, OH

Coverage and accumulators

Found by member ID

Plan
- PPO group UNKNOWN
Coverage period
2021-07-01 to 2026-02-02
Deductible
$1,860.25 of $3,500.0053%
Out-of-pocket maximum
$3,484.78 of $10,500.0033%
Copays
office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits
19 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
1642343457
Network
In network
Rendering NPI
8405936690
Location
Tempe, AZ · TIN 66-7462916
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
111403Excision benign lesion, trunk, 2.1-3.0 cm—11$614.00$380.68——DeniedCO27
Totals$614.00$380.68——
Diagnoses (ICD-10-CM)
  • 1. L30.9 Dermatitis, unspecifiedprincipal
  • 2. L40.0 Psoriasis vulgaris
Claim header
Patient account
PA-485393
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

CheckResultCodeDetail
Member identityPassAttached to MBR-007659 (verified, link confidence 1.00).
EligibilityFailCO27Date of service 2026-08-23 is after coverage terminated on 2026-02-02.
Expenses incurred after coverage terminated
Timely filingPassReceived 17 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Dermatology Clinic (1642343457).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Evergreen Dermatology Clinic2026-08-23 16:04

    Patient seen for dermatitis, unspecified.

  • SystemSystem: Claims system2026-09-09 02:18

  • AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-09 14:32

    Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Eligibility: Date of service 2026-08-23 is after coverage terminated on 2026-02-02.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity