Professional claim · CMS-1500 · EDI 837P
CLM-2026-033078
Sunrise Dermatology Clinic, Dermatology. Service 2026-03-29 at office (POS 11). Received 2026-05-12.
Denied
Billed
$407.00
2 lines
Allowed
$252.34
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Sean Dixon
- Member ID
- UHC-62395-04
- Date of birth
- 2000-10-04
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-417927
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3261
- Coverage period
- 2022-02-01 to 2026-03-25
- Deductible
- $1,136.74 of $1,500.0076%
- Out-of-pocket maximum
- $561.62 of $3,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 6454024715
- Location
- Miami, FL · TIN 81-2411732
- 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 | $201.00 | $124.62 | — | — | DeniedCO27 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $206.00 | $127.72 | — | — | DeniedCO27 |
| Totals | $407.00 | $252.34 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. L40.0 Psoriasis vulgarisprincipal
Claim header
- Patient account
- PA-247908
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000059 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-29 is after coverage terminated on 2026-03-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 (3046094173). | |
| 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 Clinic2026-03-29 17:23
Patient seen for psoriasis vulgaris.
- SystemSystem: Claims system2026-05-12 01:31
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 2026-03-29 is after coverage terminated on 2026-03-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001048 | 2026-05-30 | Heritage GI Associates | $219.00 | Denied |
| CLM-2026-020451 | 2026-02-27 | Heritage Behavioral Health | $312.00 | Denied |
| CLM-2026-020450 | 2026-02-27 | Heritage Behavioral Health | $312.00 | 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.