CLM-2026-014344
Lakeside Skin Care Associates, Dermatology. Service 2025-08-29 at office (POS 11). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Lori Franklin
- Member ID
- UHC-98775-39
- Date of birth
- 1982-04-15
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-428681
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0309
- Coverage period
- 2021-05-01 to 2026-07-27
- Deductible
- $310.37 of $500.0062%
- Out-of-pocket maximum
- $893.06 of $2,000.0045%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7845642215
- Network
- In network
- Rendering NPI
- 9388276161
- Location
- Miami, FL · TIN 41-5264398
- 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 | $590.00 | $365.80 | — | — | DeniedCO29 |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 2 | $209.00 | $129.58 | — | — | DeniedCO29 |
| Totals | $799.00 | $495.38 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- Patient account
- PA-478456
- 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-018271 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-08-29: NULL (PPO), effective 2021-05-01, terms 2026-07-27. | |
| Timely filing | Fail | CO29 | Received 191 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Skin Care Associates (7845642215). | |
| 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 Associates2025-08-29 10:31
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-03-08 03:56
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 191 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013345 | 2026-06-12 | Mesa Family Practice | $214.00 | 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
Received after the timely-filing limit.