CLM-2026-017867
Valley Skin Care Associates, Dermatology. Service 2026-02-17 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Elizabeth Sanitago
- Member ID
- UHC-41576-25
- Date of birth
- 2002-01-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414469
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3568
- Coverage period
- 2022-07-01 to present
- Deductible
- $709.05 of $1,000.0071%
- Out-of-pocket maximum
- $1,135.74 of $3,000.0038%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 7651834484
- Location
- Scottsdale, AZ · TIN 26-4772029
- 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 | $225.00 | $101.25 | — | — | DeniedCO204 |
| 2 | 11102 | Tangential skin biopsy, single lesion | 25 | 1 | 2 | $233.00 | $104.85 | — | — | DeniedCO204 |
| Totals | $458.00 | $206.10 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-634532
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019963 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-17: SELECT-EPO (EPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-017866, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 8632906870 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Skin Care Associates2026-02-17 10:38
Follow-up for actinic keratosis. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-20 03:48
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-017866, billed by a different provider. Provider network: Billing provider 8632906870 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017866 | 2026-02-17 | Unity Dermatology Clinic | $458.00 | Approved |
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
Different billing provider; separately payable.