CLM-2026-008681
Lakeside Dermatology Clinic, Dermatology. Service 2026-02-25 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Dylan Stone
- Member ID
- UHC-00232-43
- Date of birth
- 1961-03-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403301
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1201
- Coverage period
- 2025-04-01 to present
- Deductible
- $71.85 of $3,500.002%
- Out-of-pocket maximum
- $4,438.44 of $14,000.0032%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 1088536119
- Location
- Charlotte, NC · TIN 35-6038374
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $312.00 | $193.44 | — | — | DeniedCO18 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $212.00 | $131.44 | — | — | DeniedCO18 |
| Totals | $524.00 | $324.88 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- Patient account
- PA-557815
- 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-009200 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: NULL (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-008680: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Dermatology Clinic (6608515485). | |
| 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: Lakeside Dermatology Clinic2026-02-25 17:26
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-20 00:17
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-008680: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021349 | 2026-03-03 | Unity Reference Lab | $86.00 | Needs review |
| CLM-2026-021348 | 2026-03-03 | Unity Reference Lab | $86.00 | Approved |
| CLM-2026-008680 | 2026-02-25 | Lakeside Dermatology Clinic | $524.00 | Approved |
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
Exact duplicate of an earlier submission.