CLM-2026-022687
Sunrise Dermatology Clinic, Dermatology. Service 2026-02-20 at office (POS 11). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Jack Fowler
- Member ID
- UHC-96462-49
- Date of birth
- 1955-03-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412520
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1956
- Coverage period
- 2022-09-01 to present
- Deductible
- $257.40 of $500.0051%
- Out-of-pocket maximum
- $142.28 of $1,500.009%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 9318370597
- Network
- In network
- Rendering NPI
- 6553857460
- Location
- Los Angeles, CA · TIN 15-7693212
- 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 | — | 1 | 1 | $270.00 | $167.40 | — | — | DeniedCO29 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 2 | $485.00 | $300.70 | — | — | DeniedCO29 |
| Totals | $755.00 | $468.10 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-368699
- 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-033680 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-20: MEDICARE-ADV-A (MA), effective 2022-09-01. | |
| Timely filing | Fail | CO29 | Received 105 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 Sunrise Dermatology Clinic (9318370597). | |
| 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 Clinic2026-02-20 14:15
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-06-05 05:38
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 105 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011896 | 2026-07-17 | Meadow Primary Care Associates | $18.00 | Denied |
| CLM-2026-028661 | 2026-07-21 | Riverside Medical Group | $2,765.00 | Needs review |
| CLM-2026-011895 | 2026-07-17 | Meadow Primary Care Associates | $18.00 | 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
Received after the timely-filing limit.