CLM-2026-006265
Sunrise Dermatology Clinic, Dermatology. Service 2026-06-19 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Austin Hanson
- Member ID
- UHC-99877-94
- Date of birth
- 1974-09-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413482
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2231
- Coverage period
- 2023-04-01 to present
- Deductible
- $92.91 of $500.0019%
- Out-of-pocket maximum
- $543.13 of $2,000.0027%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 1795175763
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- none / REF887320
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 | $658.00 | $296.10 | — | — | DeniedCO204 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $249.00 | $112.05 | — | — | DeniedCO204 |
| Totals | $907.00 | $408.15 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-956048
- 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-032333 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-19: CORE-HMO (HMO), effective 2023-04-01. | |
| Timely filing | Pass | Received 19 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 | Fail | CO204 | Billing provider 2690461902 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Clinic2026-06-19 10:16
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-08 00:56
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-08 14:42
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 engineDenied2026-10-22 12:44Provider network: Billing provider 2690461902 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.