CLM-2026-001050
Valley Skin Care Associates, Dermatology. Service 2026-04-29 at office (POS 11). Received 2026-05-01.
Member
Resolved through the identity graph
- Member
- Ashley Carter
- Member ID
- UHC-23575-96
- Date of birth
- 1951-02-25
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-431778
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8101
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,196.52 of $1,500.0080%
- Out-of-pocket maximum
- $61.75 of $4,500.001%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 2987742436
- Network
- In network
- Rendering NPI
- 2527876439
- Location
- Miami, FL · TIN 36-7948934
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $183.00 | $113.46 | $75.00 | $38.46 | Paid |
| Totals | $183.00 | $113.46 | $75.00 | $38.46 | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-700758
- 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-028591 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-29: OPTIONS-PPO (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 2 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 Valley Skin Care Associates (2987742436). | |
| 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: Valley Skin Care Associates2026-04-29 13:41
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-01 06:12
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-01 14:27
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-700758.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.