CLM-2026-020489
Evergreen Dermatology Clinic, Dermatology. Service 2026-06-30 at office (POS 11). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Ahmed Hudson
- Member ID
- UHC-89402-89
- Date of birth
- 1963-04-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417383
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5043
- Coverage period
- 2024-02-01 to 2026-02-26
- Deductible
- $384.54 of $1,500.0026%
- Out-of-pocket maximum
- $2,547.87 of $6,000.0042%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 1620382568
- Location
- Mesa, AZ · TIN 16-2434239
- Authorisation / referral
- none / REF619836
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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $619.00 | $278.55 | — | — | DeniedCO27 |
| Totals | $619.00 | $278.55 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-743132
- 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-024198 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-30 is after coverage terminated on 2026-02-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 25 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 | Fail | CO204 | Billing provider 5921287756 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Evergreen Dermatology Clinic2026-06-30 15:58
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-25 04:45
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-25 17:11
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-30 is after coverage terminated on 2026-02-26. Provider network: Billing provider 5921287756 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.