CLM-2026-017156
Lakeside Dermatology Clinic, Dermatology. Service 2026-06-28 at office (POS 11). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Steven Rios
- Member ID
- UHC-51797-42
- Date of birth
- 1985-12-12
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-420119
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4324
- Coverage period
- 2021-07-01 to present
- Deductible
- $2.50 of $1,000.000%
- Out-of-pocket maximum
- $761.81 of $4,000.0019%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 5044214612
- Location
- Charlotte, NC · TIN 35-6038374
- Authorisation / referral
- none / REF719011
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 | $269.00 | $166.78 | — | — | DeniedCO29 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1,2 | $212.00 | $131.44 | — | — | DeniedCO29 |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 2 | $185.00 | $114.70 | — | — | DeniedCO29 |
| Totals | $666.00 | $412.92 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-963040
- 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-021387 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-28: NAVIGATE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Fail | CO29 | Received 103 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 Lakeside Dermatology Clinic (6608515485). | |
| 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: Lakeside Dermatology Clinic2026-06-28 11:41
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-10-09 02:22
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 engineDenied2026-10-21 13:43Timely filing: Received 103 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016748 | 2026-03-17 | Mesa Orthopedic Specialists | $1,132.00 | Denied |
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.