Claims workbench/CLM-2026-031464
Professional claim · CMS-1500 · Provider portal

CLM-2026-031464

Mesa Dermatology Clinic, Dermatology. Service 2026-02-04 at office (POS 11). Received 2026-09-10.

Denied
Billed
$650.00
1 line
Allowed
$403.00
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Michael McDonald
Member ID
UHC-87977-24
Date of birth
1982-07-05
Identity
Verified5 records, confidence 0.99
Claim record
CLMCLM-431870
Relationship
Spouse, Gilbert, AZ

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-6146
Coverage period
2021-01-01 to present
Deductible
$2,479.89 of $3,500.0071%
Out-of-pocket maximum
$3,620.99 of $10,500.0034%
Copays
office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
6249986509
Network
In network
Rendering NPI
8239942849
Location
Nashville, TN · TIN 73-5403948
Authorisation / referral
none / REF850784

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
111403Excision benign lesion, trunk, 2.1-3.0 cm—11$650.00$403.00——DeniedCO29
Totals$650.00$403.00——
Diagnoses (ICD-10-CM)
  • 1. L40.0 Psoriasis vulgarisprincipal
  • 2. D22.5 Melanocytic nevi of trunk
Claim header
Patient account
PA-882571
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

CheckResultCodeDetail
Member identityPassAttached to MBR-011892 (verified, link confidence 0.99).
EligibilityPassActive on 2026-02-04: CORE-HMO (HMO), effective 2021-01-01.
Timely filingFailCO29Received 218 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Dermatology Clinic (6249986509).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Clinic2026-02-04 11:25

    Patient seen for psoriasis vulgaris.

  • SystemSystem: Claims system2026-09-10 00:32

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Timely filing: Received 218 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity