CLM-2026-030200
Evergreen Dermatology Clinic, Dermatology. Service 2026-07-31 at office (POS 11). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Shirley Fowler
- Member ID
- UHC-32210-23
- Date of birth
- 1996-01-19
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-403856
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5598
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,516.68 of $2,500.0061%
- Out-of-pocket maximum
- $343.51 of $10,000.003%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5921287756
- Network
- Out of network
- Rendering NPI
- 8371081307
- Location
- Mesa, AZ · TIN 16-2434239
- Authorisation / referral
- none / REF328335
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 | $165.00 | $74.25 | — | — | DeniedCO204 |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $294.00 | $132.30 | — | — | DeniedCO204 |
| Totals | $459.00 | $206.55 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-691552
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020138 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-31: NAVIGATE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 12 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 HMO 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) | 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: Evergreen Dermatology Clinic2026-07-31 11:57
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-12 00:02
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 engineDenied2026-10-22 12:44Provider network: Billing provider 5921287756 is out of network and the HMO plan has no out-of-network benefit. Bundling (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
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.