CLM-2026-017322
Sunrise Dermatology Clinic, Dermatology. Service 2026-04-28 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Ashley Thomas
- Member ID
- UHC-49242-29
- Date of birth
- 1983-03-07
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400891
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3924
- Coverage period
- 2021-06-01 to present
- Deductible
- $839.41 of $1,500.0056%
- Out-of-pocket maximum
- $739.78 of $3,000.0025%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 3368572897
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $565.00 | $350.30 | $60.00 | $290.30 | Paid |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $223.00 | $138.26 | $0.00 | $138.26 | Paid |
| 3 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1,2 | $291.00 | $180.42 | $0.00 | $180.42 | Paid |
| Totals | $1,079.00 | $668.98 | $60.00 | $608.98 | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-135343
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012554 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-28: CHOICE-PLUS-PPO (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 37 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 Clinic2026-04-28 11:03
Follow-up for melanocytic nevi of trunk. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-04 00:59
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-135343.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.