Professional claim · CMS-1500 · EDI 837P
CLM-2026-028344
Evergreen Dermatology Clinic, Dermatology. Service 2026-06-01 at office (POS 11). Received 2026-06-23.
Approved
Billed
$950.00
2 lines
Allowed
$589.00
contract rate applied
Plan pays
$514.00
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
- Dennis Ray
- Member ID
- UHC-11585-25
- Date of birth
- 1961-07-12
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420714
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0529
- Coverage period
- 2024-12-01 to present
- Deductible
- $1,175.92 of $2,500.0047%
- Out-of-pocket maximum
- $2,231.72 of $7,500.0030%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 8635810756
- Location
- Tempe, AZ · TIN 66-7462916
- 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 | $683.00 | $423.46 | $75.00 | $348.46 | Paid |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $267.00 | $165.54 | $0.00 | $165.54 | Paid |
| Totals | $950.00 | $589.00 | $75.00 | $514.00 | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L30.9 Dermatitis, unspecified
Claim header
- Patient account
- PA-393280
- 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-021384 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-01: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 22 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 Evergreen Dermatology Clinic (1642343457). | |
| 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: Evergreen Dermatology Clinic2026-06-01 15:25
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$950.00
Plan discount
$361.00
contracted rate
Plan paid
$514.00
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-2026-020504 | 2026-06-05 | Canyon Internal Medicine Associates | $186.00 | Approved |
| CLM-2026-027625 | 2026-04-14 | Pinecrest Regional Medical Center | $2,494.00 | Needs review |
| CLM-2026-027624 | 2026-04-14 | Pinecrest Regional Medical Center | $2,494.00 | Approved |
| CLM-2026-023035 | 2026-03-01 | Sunrise Orthopedic Specialists | $42,280.00 | 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.