Professional claim · CMS-1500 · Paper
CLM-2026-025369
Sunrise Skin Care Associates, Dermatology. Service 2026-04-06 at office (POS 11). Received 2026-05-02.
Approved
Billed
$277.00
1 line
Allowed
$171.74
contract rate applied
Plan pays
$111.74
approved
Member owes
$60.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Matthew Nguyen
- Member ID
- UHC-76482-85
- Date of birth
- 1999-02-14
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-428311
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1504
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,156.30 of $2,500.0086%
- Out-of-pocket maximum
- $464.38 of $5,000.009%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 1951970627
- Network
- In network
- Rendering NPI
- 5096871244
- Location
- Dallas, TX · TIN 80-3585708
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $277.00 | $171.74 | $60.00 | $111.74 | Paid |
| Totals | $277.00 | $171.74 | $60.00 | $111.74 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-250143
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005536 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-06: MEDICARE-ADV-A (MA), effective 2023-02-01. | |
| Timely filing | Pass | Received 26 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 Sunrise Skin Care Associates (1951970627). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Skin Care Associates2026-04-06 11:41
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$277.00
Plan discount
$105.26
contracted rate
Plan paid
$111.74
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.