CLM-2026-031104
Sunrise Dermatology Clinic, Dermatology. Service 2026-07-20 at outpatient hospital (POS 22). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Brenda Lewis
- Member ID
- UHC-78243-99
- Date of birth
- 1977-10-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-419442
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8608
- Coverage period
- 2022-02-01 to present
- Deductible
- $852.00 of $3,500.0024%
- Out-of-pocket maximum
- $5,597.24 of $14,000.0040%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 3969313741
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- PA2025088636 / REF336169
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,593.00 | $1,166.85 | — | — | DeniedCO204 |
| Totals | $2,593.00 | $1,166.85 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. L40.0 Psoriasis vulgaris
- Patient account
- PA-677432
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036141 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-20: CORE-HMO (HMO), effective 2022-02-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025088636 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 2690461902 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Sunrise Dermatology Clinic2026-07-20 09:21
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-08-16 02:07
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2025088636_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-20 to 2026-10-18.
- Itemized billitemized_PA-677432.pdf3 pages
Itemised statement totalling $2593.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 2690461902 is out of network and the HMO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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.