CLM-2026-019534
Evergreen Dermatology Clinic, Dermatology. Service 2026-03-17 at office (POS 11). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Brittany Nichols
- Member ID
- UHC-42580-56
- Date of birth
- 1984-08-18
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-420392
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0414
- Coverage period
- 2021-01-01 to present
- Deductible
- $918.00 of $1,500.0061%
- Out-of-pocket maximum
- $1,998.13 of $6,000.0033%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 2719261127
- Location
- Mesa, AZ · TIN 16-2434239
- Authorisation / referral
- none / REF871992
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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $210.00 | $94.50 | — | — | DeniedCO204 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 2 | $546.00 | $245.70 | — | — | DeniedCO204 |
| Totals | $756.00 | $340.20 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-241688
- 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-024096 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-17: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| 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 HMO 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 Clinic2026-03-17 13:50
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-04-05 02:02
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 engineDenied2026-10-22 12:44Provider network: Billing provider 5921287756 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005601 | 2026-07-19 | Mesa Family Practice | $357.00 | Approved |
| CLM-2026-023278 | 2026-05-18 | Evergreen Medical Group | $23.00 | Approved |
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.