CLM-2026-028292
Meadow Dermatology Clinic, Dermatology. Service 2025-11-09 at office (POS 11). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Denise Jackson
- Member ID
- UHC-63308-42
- Date of birth
- 1949-03-07
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-423987
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6609
- Coverage period
- 2025-01-01 to present
- Deductible
- $776.85 of $2,500.0031%
- Out-of-pocket maximum
- $3,040.50 of $10,000.0030%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9555011474
- Network
- In network
- Rendering NPI
- 3520645789
- Location
- Austin, TX · TIN 78-9849970
- Authorisation / referral
- none / REF522648
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 | $228.00 | $141.36 | — | — | DeniedCO29 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $294.00 | $182.28 | — | — | DeniedCO29 |
| 3 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1,2 | $560.00 | $347.20 | — | — | DeniedCO29 |
| Totals | $1,082.00 | $670.84 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-290184
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010516 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-09: NAVIGATE-HMO (HMO), effective 2025-01-01. | |
| Timely filing | Fail | CO29 | Received 180 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 | Pass | In-network provider Meadow Dermatology Clinic (9555011474). | |
| 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: Meadow Dermatology Clinic2025-11-09 16:34
Patient seen for actinic keratosis.
- SystemSystem: Claims system2026-05-08 04:26
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
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 180 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026367 | 2026-08-13 | Meadow Heart Institute | $1,845.00 | Denied |
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.