CLM-2026-025327
Mesa Dermatology Clinic, Dermatology. Service 2026-07-03 at office (POS 11). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Rachel Bowman
- Member ID
- UHC-15361-15
- Date of birth
- 1962-03-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-408268
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6610
- Coverage period
- 2023-04-01 to 2026-01-20
- Deductible
- $1,954.34 of $3,500.0056%
- Out-of-pocket maximum
- $339.44 of $14,000.002%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5272774592
- Network
- In network
- Rendering NPI
- 2438332837
- Location
- Houston, TX · TIN 54-8065466
- 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 | $696.00 | $431.52 | — | — | DeniedCO27 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $251.00 | $155.62 | — | — | DeniedCO27 |
| Totals | $947.00 | $587.14 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-239038
- 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-019677 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-03 is after coverage terminated on 2026-01-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 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 (5272774592). | |
| 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 Clinic2026-07-03 13:23
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-17 05:27
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-03 is after coverage terminated on 2026-01-20.
Other claims for this member
Same resolved identity
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.