Professional claim · CMS-1500 · Provider portal
CLM-2026-023511
Meadow Dermatology Clinic, Dermatology. Service 2026-07-06 at office (POS 11). Received 2026-07-30.
Denied
Billed
$552.00
1 line
Allowed
$342.24
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Heather Singh
- Member ID
- UHC-61064-10
- Date of birth
- 1948-01-09
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-406418
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2204
- Coverage period
- 2021-02-01 to 2026-04-21
- Deductible
- $877.48 of $1,000.0088%
- Out-of-pocket maximum
- $574.52 of $4,000.0014%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9555011474
- Network
- In network
- Rendering NPI
- 4280735901
- Location
- Austin, TX · TIN 78-9849970
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $552.00 | $342.24 | — | — | DeniedCO27 |
| Totals | $552.00 | $342.24 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
Claim header
- Patient account
- PA-886773
- 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-022902 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-06 is after coverage terminated on 2026-04-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 24 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 Meadow Dermatology Clinic (9555011474). | |
| 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. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Dermatology Clinic2026-07-06 12:26
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-07-30 04:17
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-06 is after coverage terminated on 2026-04-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025437 | 2026-05-29 | Riverside Bone and Joint Center | $203.00 | Denied |
| CLM-2026-002164 | 2026-03-03 | Riverside Medical Group | $22.00 | Approved |
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
DeniedCO27scenario: Coverage terminated
Service after coverage termination.