Claims workbench/CLM-2026-020076

Professional claim · CMS-1500 · EDI 837P

CLM-2026-020076

Sunrise Skin Care Associates, Dermatology. Service 2026-03-28 at office (POS 11). Received 2026-04-20.

Denied

Billed

$769.00

2 lines

Allowed

$476.78

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Sara Reyes
Member ID: UHC-63528-39
Date of birth: 1971-04-01
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-407476
Relationship: Self, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-3344
Coverage period: 2023-11-01 to 2026-01-13
Deductible: $173.73 of $1,500.0012%
Out-of-pocket maximum: $9.32 of $3,000.000%
Copays: office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Skin Care Associates
Dermatology · taxonomy 207N00000X
NPI: 1951970627
Network: In network
Rendering NPI: 7116494262
Location: Dallas, TX · TIN 80-3585708
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	59	1	1	$187.00	$115.94	—	—	DeniedCO27
2	11403	Excision benign lesion, trunk, 2.1-3.0 cm	59	1	1	$582.00	$360.84	—	—	DeniedCO27
Totals						$769.00	$476.78	—	—

Diagnoses (ICD-10-CM)

1. L57.0 Actinic keratosisprincipal
2. D22.5 Melanocytic nevi of trunk

Claim header

Patient account: PA-212375
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-020483 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-03-28 is after coverage terminated on 2026-01-13. Expenses incurred after coverage terminated
Timely filing	Pass		Received 23 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 Sunrise Skin Care Associates (1951970627).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Skin Care Associates2026-03-28 14:53
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-04-20 00:33
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-20 09:02
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-03-28 is after coverage terminated on 2026-01-13. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-000168	2026-03-17	Canyon Cardiovascular Associates	$6,292.00	Denied
CLM-2026-008108	2026-03-13	Lakeside Internal Medicine Associates	$244.00	Denied

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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 queue Member identity