CLM-2026-009770
Sunrise Dermatology Clinic, Dermatology. Service 2026-07-05 at office (POS 11). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Sarah Barnes
- Member ID
- UHC-17925-71
- Date of birth
- 1992-05-16
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-408203
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1659
- Coverage period
- 2023-05-01 to 2026-06-23
- Deductible
- $173.72 of $500.0035%
- Out-of-pocket maximum
- $462.69 of $1,000.0046%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9318370597
- Network
- In network
- Rendering NPI
- 8006807530
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $490.00 | $303.80 | — | — | DeniedCO27 |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $263.00 | $163.06 | — | — | DeniedCO27 |
| Totals | $753.00 | $466.86 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- Patient account
- PA-367691
- 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-037496 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-05 is after coverage terminated on 2026-06-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 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 Clinic2026-07-05 13:10
Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-25 03:52
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-25 12:49
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-05 is after coverage terminated on 2026-06-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029784 | 2026-06-16 | Pinecrest Bone and Joint Center | $51,726.00 | Needs review |
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
Service after coverage termination.