CLM-2026-031885
Valley Skin Care Associates, Dermatology. Service 2026-02-20 at office (POS 11). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Jean Black
- Member ID
- none on golden record
- Date of birth
- 2006-07-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407323
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-2231
- Coverage period
- 2021-12-01 to present
- Deductible
- $83.58 of $500.0017%
- Out-of-pocket maximum
- $743.54 of $1,500.0050%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 8632906870
- Network
- Out of network
- Rendering NPI
- 6846953555
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $176.00 | $79.20 | — | — | DeniedCO204 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $700.00 | $315.00 | — | — | DeniedCO204 |
| 3 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1,2 | $229.00 | $103.05 | — | — | DeniedCO204 |
| Totals | $1,105.00 | $497.25 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- 2. L57.0 Actinic keratosis
- Patient account
- PA-800661
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002552; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-02-20: SELECT-EPO (EPO), effective 2021-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 32 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 EPO 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 Associates2026-02-20 13:13
Patient seen for melanocytic nevi of trunk.
- SystemSystem: Claims system2026-03-24 04:39
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)2026-03-24 09:21
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-002552; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-20: SELECT-EPO (EPO), effective 2021-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 8632906870 is out of network and the EPO 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.