Professional claim · CMS-1500 · EDI 837P
CLM-2026-025548
Mesa Dermatology Clinic, Dermatology. Service 2026-04-24 at office (POS 11). Received 2026-05-02.
Approved
Billed
$918.00
3 lines
Allowed
$569.16
contract rate applied
Plan pays
$529.16
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Donald Matthews
- Member ID
- UHC-95205-05
- Date of birth
- 1995-02-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416062
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7958
- Coverage period
- 2024-10-01 to present
- Deductible
- $2,831.74 of $3,500.0081%
- Out-of-pocket maximum
- $3,020.02 of $7,000.0043%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 6546896112
- Location
- San Diego, CA · TIN 46-9736501
- Authorisation / referral
- none / REF898170
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 | $182.00 | $112.84 | $40.00 | $72.84 | Paid |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1,2 | $556.00 | $344.72 | $0.00 | $344.72 | Paid |
| 3 | 11102 | Tangential skin biopsy, single lesion | 25 | 1 | 2 | $180.00 | $111.60 | $0.00 | $111.60 | Paid |
| Totals | $918.00 | $569.16 | $40.00 | $529.16 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-893485
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028854 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-24: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 8 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 (5120662585). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Dermatology Clinic2026-04-24 12:10
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$918.00
Plan discount
$348.84
contracted rate
Plan paid
$529.16
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026053 | 2026-06-20 | Heritage Rehabilitation Center | $214.00 | Approved |
| CLM-2026-012843 | 2026-04-02 | Lakeside Bone and Joint Center | $36,393.00 | Needs review |
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.