CLM-2026-032465
Northgate Dermatology Clinic, Dermatology. Service 2026-05-13 at office (POS 11). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Andrea Stewart
- Member ID
- UHC-90829-10
- Date of birth
- 1963-09-05
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-423213
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9735
- Coverage period
- 2023-02-01 to present
- Deductible
- $263.81 of $500.0053%
- Out-of-pocket maximum
- $50.44 of $1,000.005%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 2906165677
- Location
- Mesa, AZ · TIN 98-6879674
- 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 | 17110 | Destruction of benign lesions, up to 14 | — | 1 | 1 | $184.00 | $114.08 | — | — | Review |
| 2 | 11102 | Tangential skin biopsy, single lesion | — | 1 | 1 | $287.00 | $177.94 | — | — | Review |
| Totals | $471.00 | $292.02 | — | — | ||||||
- 1. L57.0 Actinic keratosisprincipal
- Patient account
- PA-405707
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-028566 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-13: MEDICARE-ADV-A (MA), effective 2023-02-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-032464; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Dermatology Clinic (7707045416). | |
| 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: Northgate Dermatology Clinic2026-05-13 11:54
Established patient presents with actinic keratosis; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-05-28 02:54
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-032464.pdf1 page
Provider cover letter requesting replacement of CLM-2026-032464.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-032464; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032464 | 2026-05-13 | Northgate Dermatology Clinic | $471.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.