CLM-2026-022514
Sunrise Dermatology Clinic, Dermatology. Service 2025-12-13 at office (POS 11). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Andrea Grean
- Member ID
- none on golden record
- Date of birth
- 1957-10-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431635
- Relationship
- Self
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 3046094173
- Network
- In network
- Rendering NPI
- 4297885145
- Location
- Miami, FL · TIN 81-2411732
- 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 | 17110 | Destruction of benign lesions, up to 14 | 59 | 1 | 1 | $199.00 | $123.38 | — | — | PendedIDQ |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 1 | $285.00 | $176.70 | — | — | PendedIDQ |
| 3 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | 25 | 1 | 1 | $633.00 | $392.46 | — | — | PendedIDQ |
| Totals | $1,117.00 | $692.54 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- Patient account
- PA-557831
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001350; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 34 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 Sunrise Dermatology Clinic (3046094173). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Clinic2025-12-13 11:44
Follow-up for melanocytic nevi of trunk. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-16 00:17
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-16 12:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-557831.pdf19 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001350; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.