Claims workbench/CLM-2026-002721
Professional claim · CMS-1500 · EDI 837P

CLM-2026-002721

Evergreen Counseling Center, Behavioral Health. Service 2026-08-15 at office (POS 11). Received 2026-08-26.

Approved
Billed
$211.00
1 line
Allowed
$130.82
contract rate applied
Plan pays
$90.82
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Lucia Stone
Member ID
UHC-78323-14
Date of birth
1995-04-04
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-422117
Relationship
Self, Tempe, AZ

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-1909
Coverage period
2023-07-01 to present
Deductible
$447.53 of $1,500.0030%
Out-of-pocket maximum
$683.35 of $4,500.0015%
Copays
office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits
19 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Counseling Center
Behavioral Health · taxonomy 103T00000X
NPI
9886050688
Network
In network
Rendering NPI
2262026455
Location
Los Angeles, CA · TIN 43-3815206
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190834Psychotherapy, 45 minutes—11$211.00$130.82$40.00$90.82Paid
Totals$211.00$130.82$40.00$90.82
Diagnoses (ICD-10-CM)
  • 1. F32.1 Major depressive disorder, single episode, moderateprincipal
  • 2. F41.1 Generalized anxiety disorder
Claim header
Patient account
PA-444776
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

CheckResultCodeDetail
Member identityPassAttached to MBR-034764 (verified, link confidence 1.00).
EligibilityPassActive on 2026-08-15: SELECT-EPO (EPO), effective 2023-07-01.
Timely filingPassReceived 11 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Counseling Center (9886050688).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Evergreen Counseling Center2026-08-15 17:02

    Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$211.00
Plan discount
$80.18
contracted rate
Plan paid
$90.82
You may owe
$40.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity