CLM-2026-030926
Valley Skin Care Associates, Dermatology. Service 2026-06-06 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Joseph Gonzales
- Member ID
- UHC-00602-46
- Date of birth
- 1968-01-06
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-427101
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2635
- Coverage period
- 2021-12-01 to 2026-02-12
- Deductible
- $29.00 of $1,000.003%
- Out-of-pocket maximum
- $188.63 of $4,000.005%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 2531730812
- Location
- Scottsdale, AZ · TIN 26-4772029
- 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 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $525.00 | $236.25 | — | — | DeniedCO27 |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $179.00 | $80.55 | — | — | DeniedCO27 |
| Totals | $704.00 | $316.80 | — | — | ||||||
- 1. L30.9 Dermatitis, unspecifiedprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-121230
- 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-005384 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-06 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Associates2026-06-06 12:26
Follow-up for dermatitis, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-07 02:35
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-07 08:13
Called the provider office; awaiting documentation.
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 2026-06-06 is after coverage terminated on 2026-02-12. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015747 | 2026-06-17 | Meadow Bone and Joint Center | $276.00 | Denied |
| CLM-2026-033976 | 2025-12-17 | Pinecrest Primary Care Associates | $576.00 | 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
Service after coverage termination.