CLM-2026-030438
Lakeside Dermatology Clinic, Dermatology. Service 2026-09-30 at office (POS 11). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Scott Thomas
- Member ID
- UHC-23637-74
- Date of birth
- 1979-06-10
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422462
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2757
- Coverage period
- 2021-08-01 to 2026-02-14
- Deductible
- $2,028.87 of $3,500.0058%
- Out-of-pocket maximum
- $1,981.73 of $10,500.0019%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 6608515485
- Network
- In network
- Rendering NPI
- 1373235955
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $161.00 | $99.82 | — | — | DeniedCO27 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1,2 | $552.00 | $342.24 | — | — | DeniedCO27 |
| 3 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 2 | $273.00 | $169.26 | — | — | DeniedCO27 |
| Totals | $986.00 | $611.32 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. D22.5 Melanocytic nevi of trunk
- Patient account
- PA-398293
- 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-019374 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-30 is after coverage terminated on 2026-02-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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) | 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: Lakeside Dermatology Clinic2026-09-30 10:55
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-10 02:48
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-10 14:10
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 13:43Eligibility: Date of service 2026-09-30 is after coverage terminated on 2026-02-14.
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
Service after coverage termination.