CLM-2026-026171
Lakeside Dermatology Clinic, Dermatology. Service 2026-06-27 at office (POS 11). Received 2026-08-08.
Member
Resolved through the identity graph
- Member
- Kenneth George
- Member ID
- UHC-44938-15
- Date of birth
- 1945-10-13
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-412421
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5899
- Coverage period
- 2025-07-01 to present
- Deductible
- $240.04 of $1,000.0024%
- Out-of-pocket maximum
- $1,129.65 of $3,000.0038%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 4399686524
- Location
- Charlotte, NC · TIN 35-6038374
- 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 | $247.00 | $153.14 | — | — | Review |
| Totals | $247.00 | $153.14 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- Patient account
- PA-358383
- 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-003943 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-27: MEDICARE-ADV-A (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-026170, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Dermatology Clinic (6608515485). | |
| 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 Dermatology Clinic2026-06-27 17:02
Follow-up for psoriasis vulgaris. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-08-08 02:21
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-08 10:43
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-026170, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004658 | 2026-07-14 | Meadow Clinical Laboratories | $178.00 | Approved |
| CLM-2026-026170 | 2026-06-27 | Sunrise Dermatology Clinic | $247.00 | Approved |
| CLM-2026-033332 | 2025-12-20 | Meadow Regional Medical Center | $3,755.00 | 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
Different billing provider; separately payable.