Professional claim · CMS-1500 · EDI 837P
CLM-2026-034568
Valley Skin Care Associates, Dermatology. Service 2026-03-14 at office (POS 11). Received 2026-04-13.
DeniedOut of network
Billed
$203.00
1 line
Allowed
$91.35
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27, CO204
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Donna Le
- Member ID
- UHC-38557-93
- Date of birth
- 1965-02-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412874
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2627
- Coverage period
- 2021-02-01 to 2026-03-09
- Deductible
- $36.12 of $1,500.002%
- Out-of-pocket maximum
- $1,298.25 of $3,000.0043%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 4788586707
- Location
- Scottsdale, AZ · TIN 26-4772029
- Authorisation / referral
- none / REF502189
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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $203.00 | $91.35 | — | — | DeniedCO27 |
| Totals | $203.00 | $91.35 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. D22.5 Melanocytic nevi of trunkprincipal
Claim header
- Patient account
- PA-337440
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025541 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-14 is after coverage terminated on 2026-03-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 30 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 | Fail | CO204 | Billing provider 8632906870 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Skin Care Associates2026-03-14 13:38
Patient seen for melanocytic nevi of trunk.
- SystemSystem: Claims system2026-04-13 00:26
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 2026-03-14 is after coverage terminated on 2026-03-09. Provider network: Billing provider 8632906870 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023794 | 2026-03-27 | Summit Cardiovascular Associates | $8,736.00 | Denied |
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.