CLM-2026-029399
Mesa Dermatology Clinic, Dermatology. Service 2026-01-07 at office (POS 11). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Tyler Campbell
- Member ID
- UHC-99970-10
- Date of birth
- 1970-04-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413129
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5326
- Coverage period
- 2022-06-01 to 2026-05-12
- Deductible
- $1,133.28 of $3,500.0032%
- Out-of-pocket maximum
- $6,806.27 of $14,000.0049%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5272774592
- Network
- In network
- Rendering NPI
- 5264304986
- Location
- Houston, TX · TIN 54-8065466
- 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 | 59 | 1 | 1 | $486.00 | $301.32 | — | — | Review |
| 2 | 17110 | Destruction of benign lesions, up to 14 | 59 | 1 | 1,2 | $296.00 | $183.52 | — | — | Review |
| Totals | $782.00 | $484.84 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-470734
- 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-002072 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-07: MEDICARE-ADV-A (MA), effective 2022-06-01, terms 2026-05-12. | |
| Timely filing | Pass | Received 2 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 (5272774592). | |
| 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 Clinic2026-01-07 13:33
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-01-09 04:41
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-09 15:14
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-470734.pdf9 pages
Operative note describing procedures at two distinct anatomical sites.
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.
- AI recommendationApproved2026-10-21 14:15The claim is for services provided by an in-network provider to a member with active coverage. The procedures were performed at distinct anatomical sites, as documented in the operative note [A1], which justifies the use of modifier 59. The claim is within the auto-adjudication ceiling and all required documentation is present. The NCCI edit was flagged due to the use of modifier 59 on a normally bundled code pair, but the operative note confirms the distinct procedural service. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · fb8eaa34
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is for services provided by an in-network provider to a member with active coverage. The procedures were performed at distinct anatomical sites, as documented in the operative note [A1], which justifies the use of modifier 59. The claim is within the auto-adjudication ceiling and all required documentation is present. The NCCI edit was flagged due to the use of modifier 59 on a normally bundled code pair, but the operative note confirms the distinct procedural service. Therefore, the claim is approved.
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
Modifier 59 supported: distinct anatomical site documented.