CLM-2026-023282
Evergreen Dermatology Clinic, Dermatology. Service 2026-07-28 at office (POS 11). Received 2026-08-25.
Member
Resolved through the identity graph
- Member
- Yuki Jacobs
- Member ID
- UHC-65496-76
- Date of birth
- 1940-04-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432303
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group UNKNOWN
- Coverage period
- 2023-10-01 to present
- Deductible
- $2,026.41 of $2,500.0081%
- Out-of-pocket maximum
- $425.66 of $10,000.004%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 9121868811
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $150.00 | $93.00 | — | — | DeniedCO18 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $223.00 | $138.26 | — | — | DeniedCO18 |
| Totals | $373.00 | $231.26 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- Patient account
- PA-935742
- 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-036105 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-28: NULL (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023281: 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 Clinic2026-07-28 12:10
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-25 00:56
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-2026-023281: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023281 | 2026-07-28 | Evergreen Dermatology Clinic | $373.00 | 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.