CLM-2026-002214
Sunrise Dermatology Clinic, Dermatology. Service 2026-01-22 at office (POS 11). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Charles Porter
- Member ID
- UHC-37973-20
- Date of birth
- 2004-04-09
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-417009
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7566
- Coverage period
- 2023-12-01 to present
- Deductible
- $374.82 of $500.0075%
- Out-of-pocket maximum
- $695.45 of $2,000.0035%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 2818257539
- 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 | $530.00 | $328.60 | — | — | DeniedCO18 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $249.00 | $154.38 | — | — | DeniedCO18 |
| Totals | $779.00 | $482.98 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-386270
- 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-009724 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-22: OPTIONS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002213: 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 Clinic2026-01-22 16:05
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-16 00:00
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-16 13:23
Called the provider office; awaiting documentation.
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-2026-002213: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017290 | 2026-08-03 | Valley Imaging Center | $2,847.00 | Approved |
| CLM-2026-002213 | 2026-01-22 | Sunrise Dermatology Clinic | $779.00 | 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.