CLM-2026-029626
Mesa Dermatology Clinic, Dermatology. Service 2026-04-24 at office (POS 11). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Eugene Perez
- Member ID
- UHC-36595-86
- Date of birth
- 1995-04-11
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-419572
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7592
- Coverage period
- 2023-01-01 to present
- Deductible
- $418.47 of $1,000.0042%
- Out-of-pocket maximum
- $692.80 of $3,000.0023%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5272774592
- Network
- In network
- Rendering NPI
- 5754146251
- 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 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $229.00 | $141.98 | — | — | Review |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $180.00 | $111.60 | — | — | Review |
| Totals | $409.00 | $253.58 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-909135
- 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-025903 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-24: NULL (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 15 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 Clinic2026-04-24 09:01
Patient seen for actinic keratosis. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-05-09 05:37
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-09 08:01
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-909135.pdf15 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 engineReview2026-10-22 12:44Bundling (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.