CLM-2026-017863
Valley Skin Care Associates, Dermatology. Service 2026-01-26 at office (POS 11). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Bruce Campbell
- Member ID
- UHC-19587-40
- Date of birth
- 1972-08-02
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-410035
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8385
- Coverage period
- 2022-05-01 to present
- Deductible
- $674.88 of $1,000.0067%
- Out-of-pocket maximum
- $298.61 of $2,000.0015%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 2987742436
- Network
- In network
- Rendering NPI
- 4107712166
- Location
- Miami, FL · TIN 36-7948934
- 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 | 59 | 1 | 1 | $587.00 | $363.94 | — | — | Review |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $264.00 | $163.68 | — | — | Review |
| Totals | $851.00 | $527.62 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-595696
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010940 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-A (MA), effective 2022-05-01. | |
| Timely filing | Pass | Received 11 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 Valley Skin Care Associates (2987742436). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Valley Skin Care Associates2026-01-26 17:33
Follow-up for actinic keratosis. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-02-06 02:29
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-595696.pdf12 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Modifier 59 supported: distinct anatomical site documented.