CLM-2026-027288
Mesa Dermatology Clinic, Dermatology. Service 2026-03-08 at office (POS 11). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Fatima Armstrong
- Member ID
- none on golden record
- Date of birth
- 1995-10-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414273
- Relationship
- Self, Austin, TX
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5272774592
- Network
- In network
- Rendering NPI
- 7083161456
- Location
- Houston, TX · TIN 54-8065466
- Authorisation / referral
- none / REF876952
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 | $243.00 | $150.66 | — | — | DeniedCO18 |
| Totals | $243.00 | $150.66 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- Patient account
- PA-149627
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001481; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-027287: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Clinic2026-03-08 12:49
Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-04-18 05:09
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-18 14:04
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-001481; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-027287: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027287 | 2026-03-08 | Mesa Dermatology Clinic | $243.00 | Pended |
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
Different billing provider; separately payable.