CLM-2026-023771
Evergreen Dermatology Clinic, Dermatology. Service 2026-07-05 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Juan Williams
- Member ID
- UHC-25722-63
- Date of birth
- 1950-11-24
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-415705
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8612
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,197.46 of $2,500.0088%
- Out-of-pocket maximum
- $2,313.30 of $5,000.0046%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 7979997831
- Location
- Mesa, AZ · TIN 16-2434239
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $285.00 | $128.25 | — | — | DeniedCO18 |
| Totals | $285.00 | $128.25 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- Patient account
- PA-908296
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019216 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-07-05: MEDICARE-ADV-B (MA), effective 2022-12-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023770: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Clinic2026-07-05 18:01
Patient seen for melanocytic nevi of trunk.
- SystemSystem: Claims system2026-08-15 00:11
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-15 09:51
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-023770: same member, date of service, procedures and billing provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023770 | 2026-07-05 | Evergreen Dermatology Clinic | $285.00 | Approved |
| CLM-2026-019978 | 2026-04-19 | Summit Clinical Laboratories | $95.00 | Approved |
| CLM-2026-016974 | 2026-03-13 | Canyon Cardiovascular Associates | $1,600.00 | 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.