CLM-2026-027208
Unity Dermatology Clinic, Dermatology. Service 2025-08-18 at office (POS 11). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Frances Carpenter
- Member ID
- UHC-94353-46
- Date of birth
- 1989-07-13
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-413348
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9116
- Coverage period
- 2025-11-01 to present
- Deductible
- $246.29 of $1,500.0016%
- Out-of-pocket maximum
- $881.51 of $4,500.0020%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1114969961
- Network
- In network
- Rendering NPI
- 7139883434
- Location
- Tampa, FL · TIN 40-1762241
- 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 | $201.00 | $124.62 | — | — | DeniedN30 |
| 2 | 17110 | Destruction of benign lesions, up to 14 | 25 | 1 | 1 | $265.00 | $164.30 | — | — | DeniedN30 |
| Totals | $466.00 | $288.92 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-646238
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000097 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | Date of service 2025-08-18 is before coverage effective date 2025-11-01. Patient ineligible for this service |
| Timely filing | Fail | CO29 | Received 136 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Dermatology Clinic (1114969961). | |
| 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: Unity Dermatology Clinic2025-08-18 18:05
Patient seen for actinic keratosis.
- SystemSystem: Claims system2026-01-01 03:07
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2025-08-18 is before coverage effective date 2025-11-01. Timely filing: Received 136 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001988 | 2026-03-01 | Pinecrest Heart Institute | $687.00 | 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
Received after the timely-filing limit.