CLM-2026-002534
Lakeside Skin Care Associates, Dermatology. Service 2026-04-01 at office (POS 11). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Alan Powell
- Member ID
- UHC-25780-72
- Date of birth
- 1998-03-04
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-424322
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9821
- Coverage period
- 2025-02-01 to present
- Deductible
- $310.00 of $1,500.0021%
- Out-of-pocket maximum
- $631.07 of $4,500.0014%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7845642215
- Network
- In network
- Rendering NPI
- 2785673700
- Location
- Miami, FL · TIN 41-5264398
- 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 | $525.00 | $325.50 | — | — | Review |
| Totals | $525.00 | $325.50 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-250379
- 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-015998 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-01: CHOICE-PLUS-PPO (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-002533, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Skin Care Associates (7845642215). | |
| 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: Lakeside Skin Care Associates2026-04-01 18:14
Follow-up for actinic keratosis. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-05-07 01:46
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-07 17:04
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 engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-002533, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008520 | 2026-07-30 | Northgate Reference Lab | $38.00 | Approved |
| CLM-2026-002533 | 2026-04-01 | Valley Skin Care Associates | $525.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.