CLM-2026-000633
Sunrise Dermatology Clinic, Dermatology. Service 2026-04-16 at office (POS 11). Received 2026-04-23.
Member
Resolved through the identity graph
- Member
- Gary Burton
- Member ID
- UHC-41264-81
- Date of birth
- 1988-01-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404879
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4384
- Coverage period
- 2022-07-01 to present
- Deductible
- $262.81 of $1,000.0026%
- Out-of-pocket maximum
- $1,998.32 of $4,000.0050%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 6582401579
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- none / REF418865
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 | $638.00 | $287.10 | — | — | DeniedCO204 |
| Totals | $638.00 | $287.10 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-459608
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001487 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-16: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 7 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 2690461902 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Dermatology Clinic2026-04-16 16:42
Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-23 06:32
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-23 17:36
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 2690461902 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-2026-023600 | 2026-07-22 | Mesa Internal Medicine Associates | $238.00 | Approved |
| CLM-2026-011546 | 2026-07-30 | Valley Primary Care Associates | $293.00 | Approved |
| CLM-2026-017898 | 2025-12-31 | Valley Digestive Health Center | $286.00 | 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
No out-of-network benefit on this plan.