Professional claim · CMS-1500 · EDI 837P
CLM-2026-033419
Canyon Skin Care Associates, Dermatology. Service 2026-05-09 at office (POS 11). Received 2026-06-19.
Approved
Billed
$430.00
2 lines
Allowed
$266.60
contract rate applied
Plan pays
$226.60
approved
Member owes
$40.00
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
- Lisa Castro
- Member ID
- UHC-96067-72
- Date of birth
- 1991-01-19
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-431512
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1625
- Coverage period
- 2025-02-01 to present
- Deductible
- $459.28 of $1,000.0046%
- Out-of-pocket maximum
- $277.85 of $3,000.009%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 9534757411
- 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 | $162.00 | $100.44 | $40.00 | $60.44 | Paid |
| 2 | 11102 | Tangential skin biopsy, single lesion | 25 | 1 | 1 | $268.00 | $166.16 | $0.00 | $166.16 | Paid |
| Totals | $430.00 | $266.60 | $40.00 | $226.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. L57.0 Actinic keratosisprincipal
Claim header
- Patient account
- PA-149136
- 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-010821 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-05-09: CHOICE-PLUS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 41 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Skin Care Associates2026-05-09 13:23
Patient seen for actinic keratosis.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$430.00
Plan discount
$163.40
contracted rate
Plan paid
$226.60
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-2026-030297 | 2026-07-21 | Canyon GI Associates | $2,069.00 | Approved |
| CLM-2026-025407 | 2026-04-23 | Mesa Bone and Joint Center | $9,669.00 | Approved |
| CLM-2026-033367 | 2026-01-14 | Harbor Medical Group | $317.00 | Approved |
| CLM-2026-002982 | 2026-01-19 | Heritage Community Hospital | $762.00 | 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.