Claims workbench/CLM-2026-002850
Professional claim · CMS-1500 · EDI 837P

CLM-2026-002850

Sunrise Counseling Center, Behavioral Health. Service 2026-06-01 at telehealth (POS 02). Received 2026-06-23.

Approved
Billed
$216.00
1 line
Allowed
$133.92
contract rate applied
Plan pays
$58.92
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Raymond Delgado
Member ID
UHC-97161-69
Date of birth
1966-11-06
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-403677
Relationship
Spouse, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-5789
Coverage period
2022-10-01 to present
Deductible
$448.94 of $500.0090%
Out-of-pocket maximum
$921.53 of $2,000.0046%
Copays
office $25.00, specialist $75.00, emergency $150.00
Physical therapy visits
8 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Counseling Center
Behavioral Health · taxonomy 103T00000X
NPI
6738075996
Network
In network
Rendering NPI
6216540784
Location
Miami, FL · TIN 80-4501911
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$216.00$133.92$75.00$58.92Paid
Totals$216.00$133.92$75.00$58.92
Diagnoses (ICD-10-CM)
  • 1. F32.1 Major depressive disorder, single episode, moderateprincipal
  • 2. F43.10 Post-traumatic stress disorder, unspecified
Claim header
Patient account
PA-675425
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-017342 (verified, link confidence 1.00).
EligibilityPassActive on 2026-06-01: MEDICARE-ADV-B (MA), effective 2022-10-01.
Timely filingPassReceived 22 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Counseling Center (6738075996).
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: Sunrise Counseling Center2026-06-01 14:54

    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
$216.00
Plan discount
$82.08
contracted rate
Plan paid
$58.92
You may owe
$75.00
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