CLM-2026-027834
Evergreen Dermatology Clinic, Dermatology. Service 2026-03-06 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Albert Hoffman
- Member ID
- UHC-01119-28
- Date of birth
- 1967-12-23
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-427614
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6739
- Coverage period
- 2023-02-01 to present
- Deductible
- $302.76 of $500.0061%
- Out-of-pocket maximum
- $610.51 of $1,500.0041%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 5671991342
- Location
- Mesa, AZ · TIN 16-2434239
- 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 | $207.00 | $93.15 | — | — | DeniedCO29 |
| Totals | $207.00 | $93.15 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-465030
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025008 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-06: OPTIONS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Fail | CO29 | Received 124 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Evergreen Dermatology Clinic2026-03-06 10:50
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-08 02:26
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-08 14:45
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 124 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.