CLM-2026-000122
Lakeside Dermatology Clinic, Dermatology. Service 2025-12-23 at office (POS 11). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Joyce Mendez
- Member ID
- UHC-41945-99
- Date of birth
- 1966-04-10
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-422331
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4576
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,356.91 of $3,500.0039%
- Out-of-pocket maximum
- $793.29 of $14,000.006%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 2345501268
- Location
- Charlotte, NC · TIN 35-6038374
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $210.00 | $130.20 | $40.00 | $90.20 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $177.00 | $109.74 | $0.00 | $109.74 | Paid |
| Totals | $387.00 | $239.94 | $40.00 | $199.94 | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-893116
- 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-003733 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-23: - (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 20 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 Lakeside Dermatology Clinic (6608515485). | |
| 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: Lakeside Dermatology Clinic2025-12-23 18:01
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-12 02:27
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-893116.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
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
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.