CLM-2026-030234
Valley Skin Care Associates, Dermatology. Service 2026-08-12 at office (POS 11). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Raymond Castro
- Member ID
- UHC-84200-38
- Date of birth
- 1997-10-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404157
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0565
- Coverage period
- 2024-10-01 to present
- Deductible
- $519.75 of $3,500.0015%
- Out-of-pocket maximum
- $5,767.76 of $14,000.0041%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 9282584629
- Location
- Scottsdale, AZ · TIN 26-4772029
- Authorisation / referral
- none / REF259836
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 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $316.00 | $142.20 | — | — | DeniedCO204 |
| Totals | $316.00 | $142.20 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-324638
- 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-017899 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-12: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 34 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 | Fail | CO204 | Billing provider 8632906870 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Skin Care Associates2026-08-12 14:42
Follow-up for actinic keratosis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-15 04:57
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-15 12:12
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 8632906870 is out of network and the HMO plan has no out-of-network benefit.
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
No out-of-network benefit on this plan.