CLM-2026-028954
Mesa Dermatology Clinic, Dermatology. Service 2026-03-21 at office (POS 11). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Lopez Diane
- Member ID
- UHC-47129-97
- Date of birth
- 2008-02-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401799
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5042
- Coverage period
- 2023-10-01 to 2026-06-11
- Deductible
- $215.58 of $500.0043%
- Out-of-pocket maximum
- $53.31 of $1,500.004%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 5240494554
- 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 | — | 1 | 1 | $251.00 | $155.62 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $152.00 | $94.24 | — | — | DeniedCO18 |
| Totals | $403.00 | $249.86 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-581164
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025016 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-21: MEDICARE-ADV-A (MA), effective 2023-10-01, terms 2026-06-11. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028953: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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) | 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: Mesa Dermatology Clinic2026-03-21 09:15
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-04-14 01:13
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-028953: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017945 | 2026-09-07 | Sunrise Community Hospital | $1,353.00 | Denied |
| CLM-2026-028953 | 2026-03-21 | Mesa Dermatology Clinic | $403.00 | Approved |
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
Exact duplicate of an earlier submission.