Claims workbench/CLM-2026-000484
Professional claim · CMS-1500 · Provider portal

CLM-2026-000484

Sunrise Dermatology Clinic, Dermatology. Service 2026-05-08 at office (POS 11). Received 2026-06-02.

PendedIdentity on hold: CASE-004065
Billed
$428.00
2 lines
Allowed
$265.36
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Melissa Woong
Member ID
UHC-05164-20
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-411327
Relationship
Child, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan
N/A PPO group GRP-7943
Coverage period
2023-02-01 to present
Deductible
$156.24 of $1,500.0010%
Out-of-pocket maximum
$76.57 of $3,000.003%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
3046094173
Network
In network
Rendering NPI
4176001889
Location
Miami, FL · TIN 81-2411732
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199213Office visit, established patient, low complexity—11$159.00$98.58——PendedIDQ
211102Tangential skin biopsy, single lesion2511$269.00$166.78——PendedIDQ
Totals$428.00$265.36——
Diagnoses (ICD-10-CM)
  • 1. L57.0 Actinic keratosisprincipal
Claim header
Patient account
PA-748593
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-004065; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-05-08: N/A (PPO), effective 2023-02-01.
Timely filingPassReceived 25 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Dermatology Clinic (3046094173).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Dermatology Clinic2026-05-08 18:57

    Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-004065; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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.

Review queueMember identity