CLM-2026-028702
Unity Dermatology Clinic, Dermatology. Service 2025-12-17 at office (POS 11). Received 2026-02-14.
Member
Resolved through the identity graph
- Member
- Elizabeth Garza
- Member ID
- UHC-52036-07
- Date of birth
- 2006-09-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-422072
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group N/A
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,400.81 of $3,500.0040%
- Out-of-pocket maximum
- $2,835.01 of $7,000.0041%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 1114969961
- Network
- In network
- Rendering NPI
- 1292969965
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $214.00 | $132.68 | — | — | DeniedCO18 |
| Totals | $214.00 | $132.68 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- 2. L30.9 Dermatitis, unspecified
- Patient account
- PA-471746
- 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-008513 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-17: N/A (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 59 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028701: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Clinic2025-12-17 12:59
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-14 06:53
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-028701: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028701 | 2025-12-17 | Unity Dermatology Clinic | $214.00 | 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
Exact duplicate of an earlier submission.