CLM-2026-008300
Lakeside Skin Care Associates, Dermatology. Service 2026-09-10 at outpatient hospital (POS 22). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Nicole Gonzalez
- Member ID
- UHC-37073-66
- Date of birth
- 1959-04-24
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-424093
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5866
- Coverage period
- 2022-05-01 to present
- Deductible
- $235.82 of $500.0047%
- Out-of-pocket maximum
- $352.34 of $1,000.0035%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7845642215
- Network
- In network
- Rendering NPI
- 9677654334
- Location
- Miami, FL · TIN 41-5264398
- Authorisation / referral
- PA2026682629 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,932.00 | $1,062.60 | — | — | Review |
| Totals | $1,932.00 | $1,062.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-903589
- 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-003217 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-10: MEDICARE-ADV-A (MA), effective 2022-05-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026682629 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Skin Care Associates (7845642215). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Lakeside Skin Care Associates2026-09-10 15:25
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-10-09 03:41
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026682629_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-10 to 2026-12-09.
- Itemized billitemized_PA-903589.pdf6 pages
Itemised statement totalling $1932.00 across 1 line.
- Medical recordrecords_PA-903589.pdf10 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015273 | 2026-06-07 | Sunrise Bone and Joint Center | $425.00 | Approved |
| CLM-2026-010736 | 2026-05-26 | Sunrise Digestive Health Center | $2,367.00 | Approved |
| CLM-2026-032577 | 2026-01-01 | Lakeside Behavioral Health | $290.00 | Denied |
| CLM-2026-032576 | 2026-01-01 | Lakeside Behavioral Health | $290.00 | 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
Notes document medical necessity.