CLM-2026-014946
Northgate Dermatology Clinic, Dermatology. Service 2026-01-10 at office (POS 11). Received 2026-04-26.
Member
Resolved through the identity graph
- Member
- Andrea Collins
- Member ID
- UHC-15673-23
- Date of birth
- 1946-06-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412720
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1741
- Coverage period
- 2022-11-01 to present
- Deductible
- $265.90 of $2,500.0011%
- Out-of-pocket maximum
- $1,024.85 of $5,000.0020%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 1382319774
- Location
- Mesa, AZ · TIN 98-6879674
- 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 | $281.00 | $174.22 | — | — | DeniedCO29 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1 | $221.00 | $137.02 | — | — | DeniedCO29 |
| 3 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $180.00 | $111.60 | — | — | DeniedCO29 |
| Totals | $682.00 | $422.84 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-758184
- 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-027778 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-10: OPTIONS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Fail | CO29 | Received 106 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 Northgate Dermatology Clinic (7707045416). | |
| 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: Northgate Dermatology Clinic2026-01-10 17:40
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-26 05:31
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 106 days after the last date of service (limit 90).
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
Received after the timely-filing limit.