CLM-2026-028780
Mesa Dermatology Clinic, Dermatology. Service 2026-05-19 at office (POS 11). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Mason Alvarado
- Member ID
- UHC-58827-31
- Date of birth
- 1990-01-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-420301
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7536
- Coverage period
- 2023-02-01 to present
- Deductible
- $102.36 of $2,500.004%
- Out-of-pocket maximum
- $4,775.27 of $10,000.0048%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 3760087437
- Location
- San Diego, CA · TIN 46-9736501
- 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 | 17110 | Destruction of benign lesions, up to 14 | 59 | 1 | 1 | $173.00 | $107.26 | — | — | Review |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $236.00 | $146.32 | — | — | Review |
| Totals | $409.00 | $253.58 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-242210
- 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-000293 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-19: SELECT-EPO (EPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 19 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 Mesa Dermatology Clinic (5120662585). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Clinic2026-05-19 14:40
Follow-up for actinic keratosis. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-06-07 04:25
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-242210.pdf5 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.