CLM-2026-032123
Sunrise Dermatology Clinic, Dermatology. Service 2026-01-15 at office (POS 11). Received 2026-01-29.
Member
Resolved through the identity graph
- Member
- Vincent Jones
- Member ID
- UHC-15101-05
- Date of birth
- 1975-09-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411821
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7893
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,847.65 of $2,500.0074%
- Out-of-pocket maximum
- $3,082.36 of $7,500.0041%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 2690461902
- Network
- Out of network
- Rendering NPI
- 8134279602
- Location
- Houston, TX · TIN 60-8775890
- Authorisation / referral
- none / REF873618
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 | $166.00 | $74.70 | — | — | DeniedCO204 |
| 2 | 11403 | Excision benign lesion, trunk, 2.1-3.0 cm | — | 1 | 1 | $608.00 | $273.60 | — | — | DeniedCO204 |
| Totals | $774.00 | $348.30 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- Patient account
- PA-414206
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008664 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-15: NAVIGATE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 14 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 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 | 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: Sunrise Dermatology Clinic2026-01-15 16:39
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-29 01:54
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
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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022090 | 2026-03-06 | Pinecrest Bone and Joint Center | $46,093.00 | Needs review |
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.