CLM-2026-014956
Sunrise Dermatology Clinic, Dermatology. Service 2026-02-23 at office (POS 11). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Janice Diaz
- Member ID
- UHC-88057-73
- Date of birth
- 1987-06-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408414
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0102
- Coverage period
- 2021-02-01 to present
- Deductible
- $712.78 of $2,500.0029%
- Out-of-pocket maximum
- $3,508.83 of $7,500.0047%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 4621492550
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- none / REF496741
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 | $262.00 | $117.90 | — | — | DeniedCO204 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $228.00 | $102.60 | — | — | DeniedCO204 |
| 3 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 2 | $576.00 | $259.20 | — | — | DeniedCO204 |
| Totals | $1,066.00 | $479.70 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-318632
- 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-021279 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-23: CORE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 27 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 Clinic2026-02-23 17:36
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-03-22 05:28
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
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.