Professional claim · CMS-1500 · EDI 837P
CLM-2026-030460
Mesa Dermatology Clinic, Dermatology. Service 2026-03-26 at office (POS 11). Received 2026-04-06.
Denied
Billed
$872.00
2 lines
Allowed
$540.64
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Madison Kelly
- Member ID
- UHC-20054-54
- Date of birth
- 1952-05-25
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-423346
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2691
- Coverage period
- 2025-01-01 to 2026-02-20
- Deductible
- $381.75 of $500.0076%
- Out-of-pocket maximum
- $317.89 of $1,500.0021%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 1016397352
- Location
- San Diego, CA · TIN 46-9736501
- Authorisation / referral
- none / REF451615
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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $211.00 | $130.82 | — | — | DeniedCO27 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $661.00 | $409.82 | — | — | DeniedCO27 |
| Totals | $872.00 | $540.64 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
Claim header
- Patient account
- PA-458871
- 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-015476 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-26 is after coverage terminated on 2026-02-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 11 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) | 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Dermatology Clinic2026-03-26 11:39
Patient seen for actinic keratosis.
- SystemSystem: Claims system2026-04-06 01:46
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-26 is after coverage terminated on 2026-02-20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012362 | 2026-02-04 | Harbor Medical Group | $355.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.