CLM-2026-026145
Valley Skin Care Associates, Dermatology. Service 2026-08-18 at office (POS 11). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Mariana Anderson
- Member ID
- UHC-20476-18
- Date of birth
- 2000-10-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408553
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6663
- Coverage period
- 2021-07-01 to present
- Deductible
- $2,213.52 of $3,500.0063%
- Out-of-pocket maximum
- $4,540.98 of $10,500.0043%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 4054991110
- Location
- Scottsdale, AZ · TIN 26-4772029
- Authorisation / referral
- none / REF662677
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 | $247.00 | $111.15 | — | — | DeniedCO204 |
| Totals | $247.00 | $111.15 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-282858
- 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-007549 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-18: CORE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 45 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 HMO 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 Associates2026-08-18 18:56
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-02 02:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-02 12:18
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8632906870 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024747 | 2026-09-26 | Riverside Medical Group | $146.00 | Approved |
| CLM-2026-000364 | 2026-08-01 | Sunrise Imaging Center | $513.00 | Approved |
| CLM-2026-019821 | 2026-02-20 | Evergreen Medical Group | $528.00 | 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.