CLM-2026-019580
Meadow Dermatology Clinic, Dermatology. Service 2026-05-16 at office (POS 11). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Angela Franklin
- Member ID
- UHC-52034-94
- Date of birth
- 1977-10-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-416525
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7552
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,140.26 of $2,500.0046%
- Out-of-pocket maximum
- $2,182.28 of $7,500.0029%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9555011474
- Network
- In network
- Rendering NPI
- 3912138781
- Location
- Austin, TX · TIN 78-9849970
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $208.00 | $128.96 | $40.00 | $88.96 | Paid |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $517.00 | $320.54 | $0.00 | $320.54 | Paid |
| Totals | $725.00 | $449.50 | $40.00 | $409.50 | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- Patient account
- PA-391469
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012105 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-16: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 29 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 Meadow Dermatology Clinic (9555011474). | |
| 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: Meadow Dermatology Clinic2026-05-16 15:15
Patient seen for melanocytic nevi of trunk. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-14 04:05
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-14 12:00
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-391469.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.