CLM-2026-023629
Mesa Dermatology Clinic, Dermatology. Service 2026-09-06 at office (POS 11). Received 2026-10-13.
Member
Resolved through the identity graph
- Member
- Sean Sean
- Member ID
- UHC-92857-60
- Date of birth
- 1961-04-01
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-410046
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6893
- Coverage period
- 2023-07-01 to 2026-08-09
- Deductible
- $598.54 of $1,500.0040%
- Out-of-pocket maximum
- $1,455.15 of $4,500.0032%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6249986509
- Network
- In network
- Rendering NPI
- 7719427883
- Location
- Nashville, TN · TIN 73-5403948
- 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 | $183.00 | $113.46 | — | — | DeniedCO27 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $167.00 | $103.54 | — | — | DeniedCO27 |
| Totals | $350.00 | $217.00 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-133013
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026455 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-06 is after coverage terminated on 2026-08-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 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 Mesa Dermatology Clinic (6249986509). | |
| 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: Mesa Dermatology Clinic2026-09-06 13:54
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-13 06:21
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-13 09:19
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-06 is after coverage terminated on 2026-08-09.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032267 | 2026-06-05 | Meadow Imaging Center | $140.00 | Approved |
| CLM-2026-013802 | 2026-06-03 | Sunrise Internal Medicine Associates | $200.00 | 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
Service after coverage termination.