Professional claim · CMS-1500 · EDI 837P
CLM-2026-031623
Sunrise Dermatology Clinic, Dermatology. Service 2026-05-09 at office (POS 11). Received 2026-05-22.
Approved
Billed
$625.00
1 line
Allowed
$387.50
contract rate applied
Plan pays
$312.50
approved
Member owes
$75.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Grace Burton
- Member ID
- UHC-52024-75
- Date of birth
- 1981-01-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-400367
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3835
- Coverage period
- 2022-04-01 to 2026-08-08
- Deductible
- $228.41 of $1,500.0015%
- Out-of-pocket maximum
- $63.80 of $3,000.002%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9318370597
- Network
- In network
- Rendering NPI
- 7443489415
- Location
- Los Angeles, CA · TIN 15-7693212
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $625.00 | $387.50 | $75.00 | $312.50 | Paid |
| Totals | $625.00 | $387.50 | $75.00 | $312.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
Claim header
- Patient account
- PA-184888
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031731 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-09: MEDICARE-ADV-B (MA), effective 2022-04-01, terms 2026-08-08. | |
| Timely filing | Pass | Received 13 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 Sunrise Dermatology Clinic (9318370597). | |
| 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Dermatology Clinic2026-05-09 12:00
Patient seen for melanocytic nevi of trunk.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$625.00
Plan discount
$237.50
contracted rate
Plan paid
$312.50
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017325 | 2026-09-30 | Canyon Medical Group | $387.00 | Denied |
| CLM-2026-019128 | 2026-02-11 | Unity Community Hospital | $2,544.00 | Denied |
| CLM-2026-032117 | 2026-04-16 | Harbor Cardiovascular Associates | $221.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved 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
Approvedscenario: Clean
Clean claim, priced at contract rate.