CLM-2026-016885
Sunrise Dermatology Clinic, Dermatology. Service 2026-03-12 at office (POS 11). Received 2026-03-25.
Member
Resolved through the identity graph
- Member
- Terry Turner
- Member ID
- none on golden record
- Date of birth
- 1971-11-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-422736
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1067
- Coverage period
- 2025-08-01 to 2026-01-01
- Deductible
- $2,463.64 of $3,500.0070%
- Out-of-pocket maximum
- $2,507.89 of $7,000.0036%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 2046064384
- Location
- Miami, FL · TIN 81-2411732
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $191.00 | $118.42 | — | — | DeniedCO27 |
| Totals | $191.00 | $118.42 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-567451
- 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-009232 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-12 is after coverage terminated on 2026-01-01. Expenses incurred after coverage terminated |
| 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 | Pass | In-network provider Sunrise Dermatology Clinic (3046094173). | |
| 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 Clinic2026-03-12 16:08
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-25 03:23
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-25 13:49
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-12 is after coverage terminated on 2026-01-01.
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
Service after coverage termination.