CLM-2026-010386
Sunrise Dermatology Clinic, Dermatology. Service 2026-09-03 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Noah Coleman
- Member ID
- UHC-80842-13
- Date of birth
- —
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-412094
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7514
- Coverage period
- 2021-05-01 to 2026-08-15
- Deductible
- $200.13 of $1,500.0013%
- Out-of-pocket maximum
- $1,445.56 of $3,000.0048%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 6879178724
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- none / REF810222
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 | $382.00 | $171.90 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $155.00 | $69.75 | — | — | DeniedCO27 |
| Totals | $537.00 | $241.65 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-125060
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026762 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-03 is after coverage terminated on 2026-08-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 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 | Fail | CO204 | Billing provider 2690461902 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Clinic2026-09-03 12:29
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-11 03:14
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-11 16:17
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 2026-09-03 is after coverage terminated on 2026-08-15. Provider network: Billing provider 2690461902 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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.