CLM-2026-001385
Lakeside Behavioral Health, Behavioral Health. Service 2026-09-19 at office (POS 11). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Kimberly Armstrong
- Member ID
- UHC-44215-61
- Date of birth
- 1958-04-08
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-422780
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6267
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,741.51 of $3,500.0050%
- Out-of-pocket maximum
- $1,592.78 of $7,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 8572894938
- Location
- Austin, TX · TIN 90-0644488
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $230.00 | $103.50 | — | — | DeniedCO204 |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $279.00 | $125.55 | — | — | DeniedCO204 |
| 3 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 2 | $413.00 | $185.85 | — | — | DeniedCO204 |
| Totals | $922.00 | $414.90 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-909613
- 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-023343 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-19: SELECT-EPO (EPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 15 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 2763853613 is out of network and the EPO 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: Lakeside Behavioral Health2026-09-19 18:44
Established patient presents with adhd, combined type; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-04 00:26
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 engineDenied2026-10-21 13:43Provider network: Billing provider 2763853613 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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.