Professional claim · CMS-1500 · EDI 837P
CLM-2026-031163
Sunrise Dermatology Clinic, Dermatology. Service 2026-06-25 at office (POS 11). Received 2026-07-22.
DeniedOut of network
Billed
$622.00
2 lines
Allowed
$279.90
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Douglas Cole
- Member ID
- UHC-11333-58
- Date of birth
- 1985-09-18
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-410173
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4712
- Coverage period
- 2024-05-01 to 2026-04-18
- Deductible
- $350.78 of $500.0070%
- Out-of-pocket maximum
- $95.05 of $1,000.0010%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 3477668990
- Location
- Houston, TX · TIN 60-8775890
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $229.00 | $103.05 | — | — | DeniedCO27 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $393.00 | $176.85 | — | — | DeniedCO27 |
| Totals | $622.00 | $279.90 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
- 2. D22.5 Melanocytic nevi of trunk
Claim header
- Patient account
- PA-459673
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003818 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-25 is after coverage terminated on 2026-04-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 2690461902 is out of network and the EPO 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) | 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: Sunrise Dermatology Clinic2026-06-25 15:22
Patient seen for actinic keratosis.
- SystemSystem: Claims system2026-07-22 02:19
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-22 13:21
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-06-25 is after coverage terminated on 2026-04-18. Provider network: Billing provider 2690461902 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027612 | 2026-09-08 | Meadow Regional Medical Center | $2,976.00 | Denied |
| CLM-2026-007139 | 2025-12-13 | Harbor Rehabilitation Center | $368.00 | Approved |
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.