Professional claim · CMS-1500 · EDI 837P
CLM-2026-020290
Mesa Dermatology Clinic, Dermatology. Service 2026-02-19 at office (POS 11). Received 2026-03-10.
Approved
Billed
$519.00
2 lines
Allowed
$321.78
contract rate applied
Plan pays
$261.78
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Charlotte Lopez
- Member ID
- UHC-22887-94
- Date of birth
- 1983-09-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416447
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3267
- Coverage period
- 2023-10-01 to present
- Deductible
- $124.08 of $1,500.008%
- Out-of-pocket maximum
- $2,026.23 of $4,500.0045%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 8848027941
- Location
- San Diego, CA · TIN 46-9736501
- Authorisation / referral
- none / REF344626
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 | $299.00 | $185.38 | $60.00 | $125.38 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $220.00 | $136.40 | $0.00 | $136.40 | Paid |
| Totals | $519.00 | $321.78 | $60.00 | $261.78 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L57.0 Actinic keratosis
Claim header
- Patient account
- PA-175845
- 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-007134 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-19: NAVIGATE-HMO (HMO), effective 2023-10-01. | |
| 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 | Pass | In-network provider Mesa Dermatology Clinic (5120662585). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Dermatology Clinic2026-02-19 09:48
Patient seen for melanocytic nevi of trunk.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$519.00
Plan discount
$197.22
contracted rate
Plan paid
$261.78
You may owe
$60.00
copay, deductible and coinsurance
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004175 | 2025-12-20 | Summit Diagnostic Imaging | $226.00 | Denied |
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.