CLM-2026-000474
Summit Counseling Center, Behavioral Health. Service 2026-01-03 at office (POS 11). Received 2026-02-05.
Member
Resolved through the identity graph
- Member
- Kimberly Hill
- Member ID
- none on golden record
- Date of birth
- 1945-12-18
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-431253
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-6582
- Coverage period
- 2025-01-01 to present
- Deductible
- $134.51 of $500.0027%
- Out-of-pocket maximum
- $30.20 of $1,000.003%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4710277862
- Network
- In network
- Rendering NPI
- 9628588565
- Location
- Denver, CO · TIN 87-9149248
- Authorisation / referral
- none / REF894548
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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $167.00 | $103.54 | $75.00 | $28.54 | Paid |
| Totals | $167.00 | $103.54 | $75.00 | $28.54 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-351535
- 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-009785 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-01-03: NAVIGATE-HMO (HMO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 33 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 | Pass | In-network provider Summit Counseling Center (4710277862). | |
| 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: Summit Counseling Center2026-01-03 09:48
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2026-01-03: NAVIGATE-HMO (HMO), effective 2025-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.