Claims workbench/CLM-2026-023656
Professional claim · CMS-1500 · Paper

CLM-2026-023656

Meadow Dermatology Clinic, Dermatology. Service 2026-05-20 at office (POS 11). Received 2026-06-06.

PendedIdentity on hold: CASE-002973
Billed
$443.00
1 line
Allowed
$274.66
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Tyler West
Member ID
UHC-16776-34
Date of birth
1971-07-18
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-423594
Relationship
Self, Austin, TX

Coverage and accumulators

Found by member ID

Plan
NULL PPO group GRP-0429
Coverage period
2021-09-01 to present
Deductible
$94.84 of $1,000.009%
Out-of-pocket maximum
$1,463.44 of $4,000.0037%
Copays
office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits
8 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
9555011474
Network
In network
Rendering NPI
3314958117
Location
Austin, TX · TIN 78-9849970
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
111403Excision benign lesion, trunk, 2.1-3.0 cm—11$443.00$274.66——PendedIDQ
Totals$443.00$274.66——
Diagnoses (ICD-10-CM)
  • 1. L30.9 Dermatitis, unspecifiedprincipal
  • 2. L40.0 Psoriasis vulgaris
Claim header
Patient account
PA-140887
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 identityFailIDQMember record is in open steward case CASE-002973; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-05-20: NULL (PPO), effective 2021-09-01.
Timely filingPassReceived 17 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Dermatology Clinic (9555011474).
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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Dermatology Clinic2026-05-20 18:35

    Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002973; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

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

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity