Professional claim · CMS-1500 · EDI 837P
CLM-2026-019987
Canyon Skin Care Associates, Dermatology. Service 2026-04-12 at office (POS 11). Received 2026-05-09.
Billed
$744.00
3 lines
Allowed
$461.28
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Margaret Turner
- Member ID
- UHC-64447-70
- Date of birth
- 1983-02-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414927
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2358
- Coverage period
- 2024-10-01 to present
- Deductible
- $159.91 of $500.0032%
- Out-of-pocket maximum
- $494.46 of $2,000.0025%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 4700052846
- Location
- Nashville, TN · TIN 35-2130614
- 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 | $228.00 | $141.36 | — | — | PendedIDQ |
| 2 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1,2 | $297.00 | $184.14 | — | — | PendedIDQ |
| 3 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $219.00 | $135.78 | — | — | PendedIDQ |
| Totals | $744.00 | $461.28 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
- 2. L40.0 Psoriasis vulgaris
Claim header
- Patient account
- PA-486327
- 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 | Fail | IDQ | Member record is in open steward case CASE-003958; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-12: NULL (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 27 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 Canyon Skin Care Associates (5664814501). | |
| 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. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Skin Care Associates2026-04-12 16:11
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003958; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019988 | 2026-04-12 | Canyon Skin Care Associates | $744.00 | Pended |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.