CLM-2026-001398
Sunrise Behavioral Health, Behavioral Health. Service 2025-12-15 at telehealth (POS 02). Received 2026-01-23.
Member
Resolved through the identity graph
- Member
- William Hamilton
- Member ID
- UHC-67843-67
- Date of birth
- 1950-11-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-428103
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7028
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,812.16 of $2,500.0072%
- Out-of-pocket maximum
- $3,322.11 of $7,500.0044%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 9940642868
- Location
- Denver, CO · TIN 34-6918677
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $305.00 | $189.10 | $60.00 | $129.10 | Paid |
| Totals | $305.00 | $189.10 | $60.00 | $129.10 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-740264
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007035 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-15: OPTIONS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 39 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 Sunrise Behavioral Health (2247079397). | |
| 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: Sunrise Behavioral Health2025-12-15 13:07
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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024753 | 2026-08-22 | Mesa Family Practice | $263.00 | Approved |
| CLM-2026-018912 | 2026-09-06 | Desert Rehabilitation Center | $244.00 | Approved |
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.