Professional claim · CMS-1500 · Provider portal
CLM-2026-022004
Northgate Dermatology Clinic, Dermatology. Service 2026-03-08 at office (POS 11). Received 2026-03-26.
Approved
Billed
$229.00
1 line
Allowed
$141.98
contract rate applied
Plan pays
$81.98
approved
Member owes
$60.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Juan Carroll
- Member ID
- UHC-09236-74
- Date of birth
- 1956-10-23
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-426737
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3541
- Coverage period
- 2025-12-01 to present
- Deductible
- $149.76 of $3,500.004%
- Out-of-pocket maximum
- $1,190.42 of $14,000.009%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 1030197481
- Location
- Mesa, AZ · TIN 98-6879674
- Authorisation / referral
- none / REF974939
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 | — | 1 | 1 | $229.00 | $141.98 | $60.00 | $81.98 | Paid |
| Totals | $229.00 | $141.98 | $60.00 | $81.98 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-725215
- 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-022119 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-08: NAVIGATE-HMO (HMO), effective 2025-12-01. | |
| Timely filing | Pass | Received 18 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 Northgate Dermatology Clinic (7707045416). | |
| 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: Northgate Dermatology Clinic2026-03-08 17:44
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
$229.00
Plan discount
$87.02
contracted rate
Plan paid
$81.98
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
No other claims.
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.