CLM-2026-021135
Evergreen Dermatology Clinic, Dermatology. Service 2026-04-15 at office (POS 11). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Gerald Santos
- Member ID
- UHC-52170-31
- Date of birth
- 1975-06-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406031
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7726
- Coverage period
- 2023-07-01 to present
- Deductible
- $493.91 of $2,500.0020%
- Out-of-pocket maximum
- $561.65 of $7,500.007%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 5015256568
- Location
- Tempe, AZ · TIN 66-7462916
- 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 | $313.00 | $194.06 | — | — | DeniedCO18 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $189.00 | $117.18 | — | — | DeniedCO18 |
| Totals | $502.00 | $311.24 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-476909
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031273 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: MEDICARE-ADV-B (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 46 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021134: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Dermatology Clinic (1642343457). | |
| 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 Clinic2026-04-15 16:05
Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-31 06:54
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-021134: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021134 | 2026-04-15 | Evergreen Dermatology Clinic | $502.00 | Approved |
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
Exact duplicate of an earlier submission.