Professional claim · CMS-1500 · EDI 837P
CLM-2026-026242
Sunrise Skin Care Associates, Dermatology. Service 2026-01-02 at office (POS 11). Received 2026-01-09.
Approved
Billed
$728.00
2 lines
Allowed
$451.36
contract rate applied
Plan pays
$391.36
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Lisa Payne
- Member ID
- UHC-24880-90
- Date of birth
- 1977-09-12
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-425918
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6009
- Coverage period
- 2025-08-01 to present
- Deductible
- $173.07 of $1,500.0012%
- Out-of-pocket maximum
- $720.37 of $6,000.0012%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 1951970627
- Network
- In network
- Rendering NPI
- 7186999927
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $520.00 | $322.40 | $60.00 | $262.40 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $208.00 | $128.96 | $0.00 | $128.96 | Paid |
| Totals | $728.00 | $451.36 | $60.00 | $391.36 | ||||||
Diagnoses (ICD-10-CM)
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-716103
- 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-002853 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-02: SELECT-EPO (EPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 7 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 Associates2026-01-02 16:08
Patient seen for dermatitis, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$728.00
Plan discount
$276.64
contracted rate
Plan paid
$391.36
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030467 | 2026-02-17 | Summit Regional Medical Center | $1,712.00 | Denied |
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.