CLM-2026-028414
Evergreen Dermatology Clinic, Dermatology. Service 2026-08-21 at office (POS 11). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Edward Spencer
- Member ID
- UHC-51742-53
- Date of birth
- 1951-01-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430877
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8004
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,236.04 of $1,500.0082%
- Out-of-pocket maximum
- $1,762.60 of $6,000.0029%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 8712687622
- 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 | $309.00 | $139.05 | — | — | DeniedCO204 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $204.00 | $91.80 | — | — | DeniedCO204 |
| 3 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $419.00 | $188.55 | — | — | DeniedCO204 |
| Totals | $932.00 | $419.40 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-622263
- 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-034713 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-21: SELECT-EPO (EPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 31 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 | Fail | CO204 | Billing provider 5921287756 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Clinic2026-08-21 16:00
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-21 05:21
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 5921287756 is out of network and the EPO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.