CLM-2026-003704
Lakeside Skin Care Associates, Dermatology. Service 2026-07-14 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Arthur Lane
- Member ID
- UHC-60748-08
- Date of birth
- 1971-08-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410014
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group UNKNOWN
- Coverage period
- 2024-04-01 to present
- Deductible
- $272.41 of $500.0054%
- Out-of-pocket maximum
- $72.69 of $1,000.007%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7921872736
- Network
- In network
- Rendering NPI
- 5272246161
- Location
- Tempe, AZ · TIN 98-6599721
- Authorisation / referral
- PA2026869401 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,928.00 | $1,060.40 | — | — | Review |
| Totals | $1,928.00 | $1,060.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-191189
- 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-006013 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-14: OPTIONS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026869401 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Skin Care Associates (7921872736). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Associates2026-07-14 16:47
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-08-07 06:44
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026869401_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-14 to 2026-10-12.
- Itemized billitemized_PA-191189.pdf8 pages
Itemised statement totalling $1928.00 across 1 line.
- Medical recordrecords_PA-191189.pdf6 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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
Routine diagnosis does not support advanced imaging.