CLM-2026-016392
Sunrise Skin Care Associates, Dermatology. Service 2026-03-25 at office (POS 11). Received 2026-04-25.
Member
Resolved through the identity graph
- Member
- Rob Phillips
- Member ID
- none on golden record
- Date of birth
- 1943-11-04
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-410194
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-2287
- Coverage period
- 2023-10-01 to present
- Deductible
- $397.54 of $1,500.0027%
- Out-of-pocket maximum
- $1,238.18 of $3,000.0041%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 1951970627
- Network
- In network
- Rendering NPI
- 6888242438
- Location
- Dallas, TX · TIN 80-3585708
- Authorisation / referral
- none / REF548405
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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $237.00 | $146.94 | — | — | PendedIDQ |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $695.00 | $430.90 | — | — | PendedIDQ |
| 3 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $232.00 | $143.84 | — | — | PendedIDQ |
| Totals | $1,164.00 | $721.68 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- Patient account
- PA-410663
- 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 | Fail | IDQ | Member record is in open steward case CASE-003846; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-03-25: NAVIGATE-HMO (HMO), effective 2023-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 31 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 | Pass | In-network provider Sunrise Skin Care Associates (1951970627). | |
| 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 Skin Care Associates2026-03-25 14:46
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-003846; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-25: NAVIGATE-HMO (HMO), effective 2023-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.