CLM-2026-019637
Valley Skin Care Associates, Dermatology. Service 2026-03-23 at office (POS 11). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Joyce Snyder
- Member ID
- UHC-38342-05
- Date of birth
- 1961-01-07
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-417466
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7665
- Coverage period
- 2024-10-01 to present
- Deductible
- $2,152.91 of $2,500.0086%
- Out-of-pocket maximum
- $598.36 of $5,000.0012%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 2987742436
- Network
- In network
- Rendering NPI
- 7778450628
- Location
- Miami, FL · TIN 36-7948934
- Authorisation / referral
- none / REF364597
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 | $305.00 | $189.10 | $40.00 | $149.10 | Paid |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $183.00 | $113.46 | $0.00 | $113.46 | Paid |
| Totals | $488.00 | $302.56 | $40.00 | $262.56 | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-926904
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022300 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-23: CORE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 4 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) | 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 Associates2026-03-23 13:51
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-03-27 00:30
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-926904.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 engineApproved2026-10-21 13:43Clean 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.