CLM-2026-034542
Valley Skin Care Associates, Dermatology. Service 2025-11-26 at office (POS 11). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- Keneth Schultz
- Member ID
- UHC-13416-25
- Date of birth
- 1944-12-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403668
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3861
- Coverage period
- 2024-05-01 to present
- Deductible
- $426.72 of $3,500.0012%
- Out-of-pocket maximum
- $1,380.49 of $10,500.0013%
- Copays
- office $40.00, specialist $75.00, 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
- 8246354210
- Location
- Scottsdale, AZ · TIN 26-4772029
- Authorisation / referral
- none / REF633898
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 | $284.00 | $127.80 | — | — | DeniedCO29 |
| Totals | $284.00 | $127.80 | — | — | ||||||
- 1. D22.5 Melanocytic nevi of trunkprincipal
- Patient account
- PA-828146
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009846 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-26: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Fail | CO29 | Received 176 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 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: Valley Skin Care Associates2025-11-26 12:07
Established patient presents with melanocytic nevi of trunk; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-21 06:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-21 12:02
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 176 days after the last date of service (limit 90). Provider network: Billing provider 8632906870 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-2026-033018 | 2026-05-07 | Sunrise Cardiovascular Associates | $6,494.00 | Approved |
| CLM-2026-015826 | 2026-01-12 | Mesa Family Practice | $278.00 | 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
Received after the timely-filing limit.