CLM-2026-033145
Evergreen Dermatology Clinic, Dermatology. Service 2026-02-28 at office (POS 11). Received 2026-04-07.
Member
Resolved through the identity graph
- Member
- Charles Richards
- Member ID
- UHC-80345-16
- Date of birth
- 1999-10-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-407125
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5616
- Coverage period
- 2025-12-01 to present
- Deductible
- $67.04 of $2,500.003%
- Out-of-pocket maximum
- $1,585.60 of $10,000.0016%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1642343457
- Network
- In network
- Rendering NPI
- 7897804184
- Location
- Tempe, AZ · TIN 66-7462916
- 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 | $404.00 | $250.48 | — | — | DeniedCO18 |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 2 | $282.00 | $174.84 | — | — | DeniedCO18 |
| Totals | $686.00 | $425.32 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- Patient account
- PA-307393
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022147 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-28: OPTIONS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-033144: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Dermatology Clinic (1642343457). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Dermatology Clinic2026-02-28 14:24
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-07 03:00
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-07 10:32
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-033144: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033144 | 2026-02-28 | Evergreen Dermatology Clinic | $686.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.