Claims workbench/CLM-2026-023612
Professional claim · CMS-1500 · Provider portal

CLM-2026-023612

Northgate Dermatology Clinic, Dermatology. Service 2026-02-12 at office (POS 11). Received 2026-03-08.

Denied
Billed
$231.00
1 line
Allowed
$143.22
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Gloria Bailey
Member ID
UHC-58214-02
Date of birth
1959-02-20
Identity
Verified5 records, confidence 0.97
Claim record
CLMCLM-414551
Relationship
Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-4656
Coverage period
2023-11-01 to present
Deductible
$409.09 of $500.0082%
Out-of-pocket maximum
$661.02 of $1,500.0044%
Copays
office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits
5 of 20 used

Provider

Billing and rendering

Billing provider
Northgate Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
7707045416
Network
In network
Rendering NPI
2947945236
Location
Mesa, AZ · TIN 98-6879674
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$231.00$143.22——DeniedCO18
Totals$231.00$143.22——
Diagnoses (ICD-10-CM)
  • 1. L57.0 Actinic keratosisprincipal
  • 2. D22.5 Melanocytic nevi of trunk
Claim header
Patient account
PA-688699
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-002937 (verified, link confidence 0.97).
EligibilityPassActive on 2026-02-12: CHOICE-PLUS-PPO (PPO), effective 2023-11-01.
Timely filingPassReceived 24 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-023611: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Northgate Dermatology Clinic (7707045416).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Northgate Dermatology Clinic2026-02-12 16:59

    Patient seen for actinic keratosis.

  • SystemSystem: Claims system2026-03-08 03:57

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

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Duplicate check: Exact duplicate of CLM-2026-023611: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0003912026-07-28Meadow Diagnostic Imaging$3,826.00Needs review
CLM-2026-0236112026-02-12Northgate Dermatology Clinic$231.00Approved

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