CLM-2026-020111
Sunrise Dermatology Clinic, Dermatology. Service 2026-01-12 at office (POS 11). Received 2026-03-05.
Member
Resolved through the identity graph
- Member
- John Ramos
- Member ID
- UHC-05969-13
- Date of birth
- 1994-07-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-418628
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4294
- Coverage period
- 2025-05-01 to present
- Deductible
- $538.34 of $1,500.0036%
- Out-of-pocket maximum
- $904.56 of $6,000.0015%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 3995628765
- Location
- Miami, FL · TIN 81-2411732
- Authorisation / referral
- none / REF571129
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 | $187.00 | $115.94 | — | — | DeniedCO18 |
| Totals | $187.00 | $115.94 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-586619
- 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-001898 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-12: NAVIGATE-HMO (HMO), effective 2025-05-01. | |
| Timely filing | Pass | Received 52 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-020110: 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 Sunrise Dermatology Clinic (3046094173). | |
| 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: Sunrise Dermatology Clinic2026-01-12 15:16
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-05 05:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-05 12:13
Called the provider office; awaiting documentation.
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-2026-020110: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010955 | 2026-04-18 | Desert Internal Medicine Associates | $65.00 | Approved |
| CLM-2026-020110 | 2026-01-12 | Sunrise Dermatology Clinic | $187.00 | Approved |
| CLM-2026-004302 | 2026-02-02 | Desert Internal Medicine Associates | $3,347.00 | Needs review |
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.