Claims workbench/CLM-2026-022969
Professional claim · CMS-1500 · EDI 837P

CLM-2026-022969

Mesa Dermatology Clinic, Dermatology. Service 2026-03-05 at office (POS 11). Received 2026-03-26.

Denied
Billed
$200.00
1 line
Allowed
$124.00
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Maria Wells
Member ID
UHC-02332-78
Date of birth
1945-03-19
Identity
Verified5 records, confidence 0.88
Claim record
CLMCLM-420223
Relationship
Self, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-0601
Coverage period
2025-02-01 to present
Deductible
$330.66 of $1,500.0022%
Out-of-pocket maximum
$793.92 of $3,000.0026%
Copays
office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits
2 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
6249986509
Network
In network
Rendering NPI
4886726205
Location
Nashville, TN · TIN 73-5403948
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
111102Tangential skin biopsy, single lesion—11$200.00$124.00——DeniedCO18
Totals$200.00$124.00——
Diagnoses (ICD-10-CM)
  • 1. L30.9 Dermatitis, unspecifiedprincipal
  • 2. L40.0 Psoriasis vulgaris
Claim header
Patient account
PA-146872
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

CheckResultCodeDetail
Member identityPassAttached to MBR-018346 (verified, link confidence 0.88).
EligibilityPassActive on 2026-03-05: SELECT-EPO (EPO), effective 2025-02-01.
Timely filingPassReceived 21 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-022968: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Dermatology Clinic (6249986509).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Mesa Dermatology Clinic2026-03-05 18:27

    Patient seen for dermatitis, unspecified.

  • SystemSystem: Claims system2026-03-26 03:21

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

  • AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-26 15:14

    Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Duplicate check: Exact duplicate of CLM-2026-022968: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0209162026-02-27Meadow Reference Lab$128.00Denied
CLM-2026-0229682026-03-05Mesa Dermatology Clinic$200.00Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied 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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity