CLM-2026-014578
Sunrise Dermatology Clinic, Dermatology. Service 2026-09-27 at office (POS 11). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Victoria Knight
- Member ID
- UHC-33507-96
- Date of birth
- 1988-03-18
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-405743
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6162
- Coverage period
- 2024-05-01 to present
- Deductible
- $241.05 of $500.0048%
- Out-of-pocket maximum
- $33.52 of $1,000.003%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 7236477858
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- none / REF915754
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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $199.00 | $89.55 | — | — | DeniedCO204 |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $315.00 | $141.75 | — | — | DeniedCO204 |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $205.00 | $92.25 | — | — | DeniedCO204 |
| Totals | $719.00 | $323.55 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-494707
- 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-013679 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-27: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 13 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 Clinic2026-09-27 15:13
Patient seen for actinic keratosis.
- SystemSystem: Claims system2026-10-10 01:48
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023444 | 2026-06-07 | Canyon Primary Care Associates | $149.00 | Approved |
| CLM-2026-005192 | 2026-01-10 | Mesa Clinical Laboratories | $114.00 | 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
No out-of-network benefit on this plan.