CLM-2026-009854
Lakeside Skin Care Associates, Dermatology. Service 2026-02-21 at office (POS 11). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Aaron Rojas
- Member ID
- UHC-33961-52
- Date of birth
- 1962-10-06
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-428773
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4290
- Coverage period
- 2023-10-01 to present
- Deductible
- $181.92 of $1,000.0018%
- Out-of-pocket maximum
- $501.83 of $3,000.0017%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7921872736
- Network
- In network
- Rendering NPI
- 2932159819
- Location
- Tempe, AZ · TIN 98-6599721
- 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 | $221.00 | $137.02 | — | — | DeniedCO18 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 2 | $645.00 | $399.90 | — | — | DeniedCO18 |
| Totals | $866.00 | $536.92 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-120237
- 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-022552 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-21: SELECT-EPO (EPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 48 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-009853: 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 Skin Care Associates (7921872736). | |
| 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 Skin Care Associates2026-02-21 17:26
Patient seen for melanocytic nevi of trunk.
- SystemSystem: Claims system2026-04-10 04:28
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-10 14:13
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-009853: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009853 | 2026-02-21 | Lakeside Skin Care Associates | $866.00 | 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.