Professional claim · CMS-1500 · EDI 837P
CLM-2026-032219
Canyon Skin Care Associates, Dermatology. Service 2026-09-03 at office (POS 11). Received 2026-09-30.
Approved
Billed
$388.00
2 lines
Allowed
$240.56
contract rate applied
Plan pays
$200.56
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Philip Valdez
- Member ID
- UHC-98601-37
- Date of birth
- 2002-07-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427442
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5936
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,358.37 of $2,500.0054%
- Out-of-pocket maximum
- $1,539.41 of $10,000.0015%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 9027284477
- Location
- Nashville, TN · TIN 35-2130614
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $185.00 | $114.70 | $40.00 | $74.70 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $203.00 | $125.86 | $0.00 | $125.86 | Paid |
| Totals | $388.00 | $240.56 | $40.00 | $200.56 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-546163
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007991 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-03: SELECT-EPO (EPO), effective 2024-09-01. | |
| 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 | Pass | In-network provider Canyon Skin Care Associates (5664814501). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Skin Care Associates2026-09-03 16:07
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
$388.00
Plan discount
$147.44
contracted rate
Plan paid
$200.56
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007042 | 2026-08-07 | Harbor Physical Therapy | $9,328.00 | Needs review |
| CLM-2026-026588 | 2026-04-16 | Pinecrest Clinical Laboratories | $169.00 | 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.