CLM-2026-021809
Canyon Skin Care Associates, Dermatology. Service 2025-10-12 at office (POS 11). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Mei Nelzon
- Member ID
- UHC-07035-40
- Date of birth
- 1967-01-20
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-403209
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3622
- Coverage period
- 2025-05-01 to present
- Deductible
- $939.71 of $1,500.0063%
- Out-of-pocket maximum
- $747.27 of $3,000.0025%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 3748520939
- Location
- Nashville, TN · TIN 35-2130614
- 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 | $206.00 | $127.72 | — | — | DeniedCO29 |
| Totals | $206.00 | $127.72 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-730102
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008069 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-10-12: NULL (PPO), effective 2025-05-01. | |
| Timely filing | Fail | CO29 | Received 107 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon Skin Care Associates (5664814501). | |
| 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: Canyon Skin Care Associates2025-10-12 10:43
Established patient presents with dermatitis, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-27 04:23
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-27 13:58
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 engineDenied2026-10-22 12:44Timely filing: Received 107 days after the last date of service (limit 90).
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
Received after the timely-filing limit.