CLM-2026-004482
Canyon Skin Care Associates, Dermatology. Service 2026-06-20 at office (POS 11). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Brian Anderson
- Member ID
- UHC-99057-57
- Date of birth
- 1968-07-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-414028
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6793
- Coverage period
- 2025-05-01 to present
- Deductible
- $311.87 of $500.0062%
- Out-of-pocket maximum
- $40.75 of $1,500.003%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 5670580328
- Location
- Nashville, TN · TIN 35-2130614
- Authorisation / referral
- none / REF781615
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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $263.00 | $163.06 | — | — | PendedIDQ |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1,2 | $202.00 | $125.24 | — | — | PendedIDQ |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $203.00 | $125.86 | — | — | PendedIDQ |
| Totals | $668.00 | $414.16 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-247227
- 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 | Fail | IDQ | Member record is in open steward case CASE-003354; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-20: NAVIGATE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Pass | Received 44 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 Canyon Skin Care Associates (5664814501). | |
| 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: Canyon Skin Care Associates2026-06-20 16:33
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003354; payment withheld until the identity is confirmed.
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
Clean claim, priced at contract rate.