Professional claim · CMS-1500 · EDI 837P
CLM-2026-020346
Sunrise Skin Care Associates, Dermatology. Service 2026-04-20 at office (POS 11). Received 2026-05-27.
Approved
Billed
$586.00
3 lines
Allowed
$363.32
contract rate applied
Plan pays
$313.32
approved
Member owes
$50.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Ryan Riley
- Member ID
- UHC-78345-09
- Date of birth
- 1987-02-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411705
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3532
- Coverage period
- 2022-09-01 to present
- Deductible
- $373.15 of $500.0075%
- Out-of-pocket maximum
- $329.70 of $1,000.0033%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 1951970627
- Network
- In network
- Rendering NPI
- 8362127630
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $191.00 | $118.42 | $50.00 | $68.42 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $183.00 | $113.46 | $0.00 | $113.46 | Paid |
| 3 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1,2 | $212.00 | $131.44 | $0.00 | $131.44 | Paid |
| Totals | $586.00 | $363.32 | $50.00 | $313.32 | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-285738
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028577 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-20: SELECT-EPO (EPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 37 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) | 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Skin Care Associates2026-04-20 09:48
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$586.00
Plan discount
$222.68
contracted rate
Plan paid
$313.32
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032659 | 2026-08-03 | Pinecrest Heart Institute | $574.00 | Denied |
| CLM-2026-032658 | 2026-08-03 | Pinecrest Heart Institute | $574.00 | Approved |
| CLM-2026-020347 | 2026-04-20 | Sunrise Skin Care Associates | $586.00 | 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.