CLM-2026-026881
Lakeside Dermatology Clinic, Dermatology. Service 2026-05-01 at office (POS 11). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Helen Harvey
- Member ID
- none on golden record
- Date of birth
- 1942-02-24
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-402385
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 7547472317
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | 59 | 1 | 1 | $537.00 | $332.94 | — | — | PendedN30 |
| 2 | 11102 | Tangential skin biopsy, single lesion | 59 | 1 | 2 | $248.00 | $153.76 | — | — | PendedN30 |
| Totals | $785.00 | $486.70 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-216231
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032897 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 29 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 Dermatology Clinic (6608515485). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Clinic2026-05-01 09:03
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-05-30 05:17
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-30 09:04
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Medical recordrecords_PA-216231.pdf5 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Modifier 59 supported: distinct anatomical site documented.