CLM-2026-006105
Valley Skin Care Associates, Dermatology. Service 2026-09-05 at office (POS 11). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Kelly Richardson
- Member ID
- none on golden record
- Date of birth
- 1998-06-13
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406714
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-8096
- Coverage period
- 2024-12-01 to present
- Deductible
- $2,196.90 of $2,500.0088%
- Out-of-pocket maximum
- $4,254.19 of $10,000.0043%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 3600293328
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $315.00 | $141.75 | — | — | PendedIDQ |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 2 | $289.00 | $130.05 | — | — | PendedIDQ |
| Totals | $604.00 | $271.80 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-582262
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000585; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-09-05: OPTIONS-PPO (PPO), effective 2024-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 3 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-09-05 18:20
Established patient presents with actinic keratosis; 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-000585; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-05: OPTIONS-PPO (PPO), effective 2024-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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.