Professional claim · CMS-1500 · Provider portal
CLM-2026-019270
Sunrise Dermatology Clinic, Dermatology. Service 2026-03-24 at office (POS 11). Received 2026-04-01.
ApprovedOut of network
Billed
$408.00
2 lines
Allowed
$183.60
contract rate applied
Plan pays
$143.60
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Dorothy Bradley
- Member ID
- UHC-61130-89
- Date of birth
- 1952-09-12
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-421257
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3375
- Coverage period
- 2025-11-01 to present
- Deductible
- $862.06 of $1,000.0086%
- Out-of-pocket maximum
- $811.68 of $2,000.0041%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 1540583477
- Location
- Houston, TX · TIN 60-8775890
- 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 | $210.00 | $94.50 | $40.00 | $54.50 | Paid |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $198.00 | $89.10 | $0.00 | $89.10 | Paid |
| Totals | $408.00 | $183.60 | $40.00 | $143.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-635501
- 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-001864 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-24: CHOICE-PLUS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 8 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: Sunrise Dermatology Clinic2026-03-24 18:28
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$408.00
Plan discount
$224.40
out-of-network allowance
Plan paid
$143.60
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-2026-002668 | 2026-09-28 | Heritage Community Hospital | $696.00 | Approved |
| CLM-2026-023324 | 2026-08-01 | Heritage Primary Care Associates | $59.00 | Approved |
| CLM-2026-019659 | 2026-03-28 | Sunrise Imaging Center | $1,951.00 | Needs review |
| CLM-2026-008213 | 2025-12-17 | Heritage Medical Group | $42.00 | 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.