CLM-2026-019679
Meadow Skin Care Associates, Dermatology. Service 2026-09-30 at office (POS 11). Received 2026-11-01.
Member
Resolved through the identity graph
- Member
- Christopher Mendez
- Member ID
- UHC-51704-12
- Date of birth
- 1967-07-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404620
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2549
- Coverage period
- 2023-03-01 to present
- Deductible
- $353.16 of $500.0071%
- Out-of-pocket maximum
- $307.00 of $2,000.0015%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5570109764
- Network
- In network
- Rendering NPI
- 5571857635
- Location
- Miami, FL · TIN 98-6447059
- Authorisation / referral
- none / REF331546
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 | $514.00 | $318.68 | — | — | DeniedCO18 |
| Totals | $514.00 | $318.68 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-458491
- 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-024250 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-30: NAVIGATE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-019678: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow Skin Care Associates (5570109764). | |
| 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: Meadow Skin Care Associates2026-09-30 15:46
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-11-01 01:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-019678: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019678 | 2026-09-30 | Meadow Skin Care Associates | $514.00 | Approved |
| CLM-2026-030176 | 2026-05-12 | Evergreen Family Practice | $208.00 | Needs review |
| CLM-2026-032923 | 2026-03-25 | Riverside Family Practice | $57.00 | 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
Exact duplicate of an earlier submission.