CLM-2026-007939
Sunrise Dermatology Clinic, Dermatology. Service 2026-06-04 at office (POS 11). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Michelle Clark
- Member ID
- UHC-76779-12
- Date of birth
- 1987-06-28
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421319
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9549
- Coverage period
- 2023-04-01 to present
- Deductible
- $931.77 of $2,500.0037%
- Out-of-pocket maximum
- $1,678.17 of $10,000.0017%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9318370597
- Network
- In network
- Rendering NPI
- 7679935735
- Location
- Los Angeles, CA · TIN 15-7693212
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $187.00 | $115.94 | — | — | Review |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $219.00 | $135.78 | — | — | Review |
| Totals | $406.00 | $251.72 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-865509
- 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-018282 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-04: NULL (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-007938, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Dermatology Clinic (9318370597). | |
| 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 Clinic2026-06-04 17:12
Patient seen for psoriasis vulgaris. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-12 00:38
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-12 16:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-007938, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013494 | 2026-06-07 | Desert Diagnostic Imaging | $4,091.00 | Approved |
| CLM-2026-007938 | 2026-06-04 | Sunrise Dermatology Clinic | $406.00 | Approved |
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
Different billing provider; separately payable.