Claims workbench/CLM-2026-008272
Professional claim · CMS-1500 · Paper

CLM-2026-008272

Sunrise Dermatology Clinic, Dermatology. Service 2026-08-08 at office (POS 11). Received 2026-08-16.

PendedIdentity on hold: CASE-003067
Billed
$910.00
2 lines
Allowed
$564.20
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Andrew Crawford
Member ID
UHC-51292-90
Date of birth
1944-10-27
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-406783
Relationship
Self, Tempe, AZ

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-9296
Coverage period
2022-01-01 to present
Deductible
$14.70 of $500.003%
Out-of-pocket maximum
$626.88 of $1,500.0042%
Copays
office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits
8 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
3046094173
Network
In network
Rendering NPI
3938063260
Location
Miami, FL · TIN 81-2411732
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
111403Excision benign lesion, trunk, 2.1-3.0 cm—11$697.00$432.14——PendedIDQ
217110Destruction of benign lesions, up to 14—11$213.00$132.06——PendedIDQ
Totals$910.00$564.20——
Diagnoses (ICD-10-CM)
  • 1. L30.9 Dermatitis, unspecifiedprincipal
  • 2. L40.0 Psoriasis vulgaris
Claim header
Patient account
PA-450036
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-003067; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-08-08: CHOICE-PLUS-PPO (PPO), effective 2022-01-01.
Timely filingPassReceived 8 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Dermatology Clinic (3046094173).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Dermatology Clinic2026-08-08 11:34

    Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-003067; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity