Professional claim · CMS-1500 · EDI 837P
CLM-2026-032961
Unity Dermatology Clinic, Dermatology. Service 2026-05-02 at office (POS 11). Received 2026-06-06.
Approved
Billed
$1,072.00
3 lines
Allowed
$664.64
contract rate applied
Plan pays
$624.64
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Lisa Hicks
- Member ID
- UHC-45936-13
- Date of birth
- 1984-01-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-413305
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1397
- Coverage period
- 2022-02-01 to present
- Deductible
- $266.33 of $500.0053%
- Out-of-pocket maximum
- $74.18 of $1,000.007%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1114969961
- Network
- In network
- Rendering NPI
- 9142889473
- Location
- Tampa, FL · TIN 40-1762241
- 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 | $657.00 | $407.34 | $40.00 | $367.34 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $181.00 | $112.22 | $0.00 | $112.22 | Paid |
| 3 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 2 | $234.00 | $145.08 | $0.00 | $145.08 | Paid |
| Totals | $1,072.00 | $664.64 | $40.00 | $624.64 | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-827323
- 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-011691 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: MEDICARE-ADV-B (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 35 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 Unity Dermatology Clinic (1114969961). | |
| 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: Unity Dermatology Clinic2026-05-02 09:23
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
$1,072.00
Plan discount
$407.36
contracted rate
Plan paid
$624.64
You may owe
$40.00
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-2026-002234 | 2025-08-01 | Canyon Diagnostic Imaging | $2,694.00 | Denied |
| CLM-2026-027735 | 2026-01-05 | Northgate Internal Medicine Associates | $184.00 | 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.