Professional claim · CMS-1500 · Paper
CLM-2026-003444
Sunrise Behavioral Health, Behavioral Health. Service 2026-04-17 at office (POS 11). Received 2026-05-11.
Approved
Billed
$212.00
1 line
Allowed
$131.44
contract rate applied
Plan pays
$71.44
approved
Member owes
$60.00
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
- Anna Harvey
- Member ID
- UHC-53608-54
- Date of birth
- 1968-10-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-429553
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6591
- Coverage period
- 2021-03-01 to 2026-05-13
- Deductible
- $610.82 of $1,500.0041%
- Out-of-pocket maximum
- $1,044.87 of $6,000.0017%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3143686582
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $212.00 | $131.44 | $60.00 | $71.44 | Paid |
| Totals | $212.00 | $131.44 | $60.00 | $71.44 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
Claim header
- Patient account
- PA-256067
- 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-019852 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-17: CORE-HMO (HMO), effective 2021-03-01, terms 2026-05-13. | |
| Timely filing | Pass | Received 24 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. |
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 Behavioral Health2026-04-17 18:52
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$212.00
Plan discount
$80.56
contracted rate
Plan paid
$71.44
You may owe
$60.00
copay, deductible and coinsurance
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-2026-011074 | 2026-09-15 | Meadow GI Associates | $4,163.00 | Denied |
| CLM-2026-025787 | 2026-03-22 | Summit Medical Group | $230.00 | Needs review |
| CLM-2026-009491 | 2026-05-05 | Northgate Medical Group | $546.00 | Approved |
| CLM-2026-025786 | 2026-03-22 | Summit Medical Group | $230.00 | Approved |
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.