CLM-2026-007573
Unity Dermatology Clinic, Dermatology. Service 2026-09-08 at office (POS 11). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Vincent Armstrong
- Member ID
- UHC-92198-01
- Date of birth
- 1980-04-15
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-400069
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4607
- Coverage period
- 2023-03-01 to present
- Deductible
- $218.18 of $1,000.0022%
- Out-of-pocket maximum
- $1,921.78 of $4,000.0048%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1114969961
- Network
- In network
- Rendering NPI
- 7759452783
- Location
- Tampa, FL · TIN 40-1762241
- 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 | 59 | 1 | 1 | $646.00 | $400.52 | — | — | Review |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $250.00 | $155.00 | — | — | Review |
| Totals | $896.00 | $555.52 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-202890
- 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-031259 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-08: SELECT-EPO (EPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 8 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 Unity Dermatology Clinic (1114969961). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Unity Dermatology Clinic2026-09-08 18:25
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-09-16 00:18
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-202890.pdf12 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Modifier 59 supported: distinct anatomical site documented.