Professional claim · CMS-1500 · Provider portal
CLM-2026-026218
Meadow Skin Care Associates, Dermatology. Service 2026-05-03 at office (POS 11). Received 2026-05-29.
Approved
Billed
$400.00
2 lines
Allowed
$248.00
contract rate applied
Plan pays
$173.00
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Cynthia Jenkins
- Member ID
- UHC-84353-34
- Date of birth
- 1996-07-15
- Identity
- Verified6 records, confidence 0.92
- Claim record
- CLMCLM-422026
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4706
- Coverage period
- 2023-06-01 to present
- Deductible
- $877.32 of $2,500.0035%
- Out-of-pocket maximum
- $3,196.85 of $10,000.0032%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5570109764
- Network
- In network
- Rendering NPI
- 3686382664
- Location
- Miami, FL · TIN 98-6447059
- Authorisation / referral
- none / REF612450
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 | $197.00 | $122.14 | $75.00 | $47.14 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $203.00 | $125.86 | $0.00 | $125.86 | Paid |
| Totals | $400.00 | $248.00 | $75.00 | $173.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
Claim header
- Patient account
- PA-656493
- 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-027951 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2026-05-03: NAVIGATE-HMO (HMO), effective 2023-06-01. | |
| 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 Meadow Skin Care Associates (5570109764). | |
| 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: Meadow Skin Care Associates2026-05-03 10:20
Patient seen for psoriasis vulgaris.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$400.00
Plan discount
$152.00
contracted rate
Plan paid
$173.00
You may owe
$75.00
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030264 | 2026-07-27 | Harbor Medical Group | $627.00 | Denied |
| CLM-2026-005058 | 2026-06-06 | Mesa Dermatology Clinic | $691.00 | Approved |
| CLM-2026-008861 | 2026-04-02 | Sunrise Community Hospital | $122.00 | 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.