CLM-2026-021275
Valley Skin Care Associates, Dermatology. Service 2026-09-04 at office (POS 11). Received 2026-09-09.
Member
Resolved through the identity graph
- Member
- Scott Ward
- Member ID
- UHC-40403-01
- Date of birth
- 1943-10-21
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414792
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4024
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,925.69 of $3,500.0055%
- Out-of-pocket maximum
- $1,419.54 of $7,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- 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
- 4350518104
- 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 | $179.00 | $80.55 | $60.00 | $20.55 | Paid |
| Totals | $179.00 | $80.55 | $60.00 | $20.55 | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-505780
- 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-005999 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-04: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 5 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-09-04 15:10
Patient seen for melanocytic nevi of trunk. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-09 06:38
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-505780.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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033256 | 2026-10-01 | Unity Primary Care Associates | $453.00 | Approved |
| CLM-2026-010129 | 2026-09-26 | Sunrise Digestive Health Center | $229.00 | Needs review |
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.