CLM-2026-024985
Lakeside Skin Care Associates, Dermatology. Service 2025-12-22 at office (POS 11). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- Gloria Sanchez
- Member ID
- UHC-28712-93
- Date of birth
- 1977-08-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414010
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2028
- Coverage period
- 2022-04-01 to present
- Deductible
- $368.89 of $1,500.0025%
- Out-of-pocket maximum
- $2,239.59 of $6,000.0037%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7921872736
- Network
- In network
- Rendering NPI
- 3070336920
- Location
- Tempe, AZ · TIN 98-6599721
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $557.00 | $345.34 | $50.00 | $295.34 | Paid |
| 2 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 2 | $215.00 | $133.30 | $0.00 | $133.30 | Paid |
| Totals | $772.00 | $478.64 | $50.00 | $428.64 | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-831333
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007739 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: NULL (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 35 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 Lakeside Skin Care Associates (7921872736). | |
| 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: Lakeside Skin Care Associates2025-12-22 17:14
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-26 00:05
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-26 17:02
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-831333.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 engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019617 | 2026-03-14 | Mesa Family Practice | $762.00 | Approved |
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.