CLM-2026-019151
Valley Skin Care Associates, Dermatology. Service 2025-11-28 at office (POS 11). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Charlotte Simmons
- Member ID
- UHC-98486-13
- Date of birth
- 1961-05-14
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-408144
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3997
- Coverage period
- 2022-11-01 to present
- Deductible
- $287.90 of $500.0058%
- Out-of-pocket maximum
- $148.13 of $1,000.0015%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 6252970630
- 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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $273.00 | $122.85 | — | — | DeniedCO204 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1,2 | $518.00 | $233.10 | — | — | DeniedCO204 |
| Totals | $791.00 | $355.95 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-556602
- 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-001182 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-11-28: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| 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 | Fail | CO204 | Billing provider 8632906870 is out of network and the HMO 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 Associates2025-11-28 11:33
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-04 05:57
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-04 11:14
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8632906870 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.