CLM-2026-024904
Valley Skin Care Associates, Dermatology. Service 2026-08-20 at office (POS 11). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Charles Gonzalez
- Member ID
- UHC-02909-70
- Date of birth
- 1974-07-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427319
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9170
- Coverage period
- 2021-01-01 to present
- Deductible
- $1,627.15 of $2,500.0065%
- Out-of-pocket maximum
- $2,173.23 of $10,000.0022%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 1052393554
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $276.00 | $124.20 | — | — | DeniedCO204 |
| Totals | $276.00 | $124.20 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- Patient account
- PA-952937
- 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-033075 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: SELECT-EPO (EPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 13 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 | Fail | CO204 | Billing provider 8632906870 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Associates2026-08-20 14:52
Patient seen for dermatitis, unspecified.
- SystemSystem: Claims system2026-09-02 04:41
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 8632906870 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013277 | 2026-06-01 | Unity Counseling Center | $491.00 | Needs review |
| CLM-2026-000808 | 2026-05-16 | Mesa Behavioral Health | $721.00 | 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
No out-of-network benefit on this plan.