CLM-2026-025161
Meadow Skin Care Associates, Dermatology. Service 2026-07-09 at office (POS 11). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Sareh Carter
- Member ID
- UHC-32006-47
- Date of birth
- 1945-05-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410085
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5780
- Coverage period
- 2023-03-01 to present
- Deductible
- $355.82 of $500.0071%
- Out-of-pocket maximum
- $211.12 of $1,500.0014%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5570109764
- Network
- In network
- Rendering NPI
- 5617769364
- Location
- Miami, FL · TIN 98-6447059
- 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 | $177.00 | $109.74 | — | — | Review |
| Totals | $177.00 | $109.74 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-994847
- 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-039295 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-09: NULL (PPO), effective 2023-03-01. | |
| 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 | Pass | In-network provider Meadow Skin Care Associates (5570109764). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals ”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Skin Care Associates2026-07-09 10:44
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-22 06:21
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-22 09:31
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals ”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005748 | 2026-08-27 | Meadow Skin Care Associates | $2,602.00 | Needs review |
| CLM-2026-017221 | 2026-08-09 | Evergreen Family Practice | $434.00 | Approved |
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
Development letter outstanding.