CLM-2026-032803
Northgate Dermatology Clinic, Dermatology. Service 2026-04-11 at office (POS 11). Received 2026-05-11.
Member
Resolved through the identity graph
- Member
- Kathy Morgan
- Member ID
- UHC-44662-69
- Date of birth
- 1994-04-23
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-417447
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2637
- Coverage period
- 2022-09-01 to present
- Deductible
- $465.30 of $3,500.0013%
- Out-of-pocket maximum
- $2,825.51 of $14,000.0020%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Dermatology ClinicDermatology · taxonomy 207N00000X
- NPI
- 7707045416
- Network
- In network
- Rendering NPI
- 3660283375
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $175.00 | $108.50 | — | — | DeniedCO18 |
| Totals | $175.00 | $108.50 | — | — | ||||||
- 1. L40.0 Psoriasis vulgarisprincipal
- Patient account
- PA-711618
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007940 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-11: MEDICARE-ADV-A (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-032802: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Clinic2026-04-11 16:54
Established patient presents with psoriasis vulgaris; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-11 06:18
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-032802: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017449 | 2026-07-24 | Lakeside Physical Therapy | $296.00 | Approved |
| CLM-2026-032802 | 2026-04-11 | Northgate Dermatology Clinic | $175.00 | Approved |
| CLM-2026-003430 | 2026-01-09 | Pinecrest Regional Medical Center | $165.00 | 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
Exact duplicate of an earlier submission.