CLM-2026-028592
Mesa Dermatology Clinic, Dermatology. Service 2026-06-01 at office (POS 11). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Daniel Oliver
- Member ID
- UHC-94684-51
- Date of birth
- 1977-10-05
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-416092
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4975
- Coverage period
- 2023-07-01 to present
- Deductible
- $151.22 of $1,500.0010%
- Out-of-pocket maximum
- $152.73 of $3,000.005%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 5120662585
- Network
- In network
- Rendering NPI
- 6299286214
- Location
- San Diego, CA · TIN 46-9736501
- 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 | $155.00 | $96.10 | — | — | DeniedCO29 |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 2 | $242.00 | $150.04 | — | — | DeniedCO29 |
| Totals | $397.00 | $246.14 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-734934
- 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-030465 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-01: UNKNOWN (PPO), effective 2023-07-01. | |
| Timely filing | Fail | CO29 | Received 97 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 Mesa Dermatology Clinic (5120662585). | |
| 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: Mesa Dermatology Clinic2026-06-01 14:20
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-06 00:55
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 13:43Timely filing: Received 97 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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.