CLM-2026-001517
Valley Skin Care Associates, Dermatology. Service 2026-04-01 at office (POS 11). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Anna Ford
- Member ID
- UHC-74396-85
- Date of birth
- 2007-09-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-403633
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group NULL
- Coverage period
- 2021-03-01 to present
- Deductible
- $300.48 of $1,000.0030%
- Out-of-pocket maximum
- $589.69 of $3,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 9998834698
- Location
- Scottsdale, AZ · TIN 26-4772029
- 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 | $419.00 | $188.55 | — | — | DeniedCO204 |
| 2 | 11102 | Tangential skin biopsy, single lesion | 25 | 1 | 1,2 | $299.00 | $134.55 | — | — | DeniedCO204 |
| Totals | $718.00 | $323.10 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-194669
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001485; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-01: SELECT-EPO (EPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 31 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 8632906870 is out of network and the EPO 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: Valley Skin Care Associates2026-04-01 18:51
Follow-up for melanocytic nevi of trunk. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-02 02:02
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-001485; payment withheld until the identity is confirmed. Provider network: Billing provider 8632906870 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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.