CLM-2026-000298
Sunrise Dermatology Clinic, Dermatology. Service 2026-04-07 at office (POS 11). Received 2026-05-26.
Member
Resolved through the identity graph
- Member
- Arjun Flores
- Member ID
- UHC-99969-24
- Date of birth
- 1978-12-09
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-409018
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1758
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,032.28 of $1,500.0069%
- Out-of-pocket maximum
- $242.77 of $3,000.008%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 8888574448
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $581.00 | $360.22 | — | — | DeniedCO18 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $260.00 | $161.20 | — | — | DeniedCO18 |
| Totals | $841.00 | $521.42 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-923321
- 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-003329 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-04-07: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 49 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-000297: 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 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Dermatology Clinic2026-04-07 17:44
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-26 04:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-26 11:45
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-000297: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022970 | 2026-06-14 | Heritage Primary Care Associates | $575.00 | Approved |
| CLM-2026-000297 | 2026-04-07 | Sunrise Dermatology Clinic | $841.00 | 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.