CLM-2026-004312
Evergreen Counseling Center, Behavioral Health. Service 2025-12-26 at telehealth (POS 02). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Kayla Webb
- Member ID
- UHC-16363-55
- Date of birth
- 1974-12-06
- Identity
- Verified2 records, confidence 0.86
- Claim record
- CLMCLM-408303
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1776
- Coverage period
- 2025-01-01 to present
- Deductible
- $65.92 of $500.0013%
- Out-of-pocket maximum
- $49.20 of $1,000.005%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 2713693747
- 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
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $275.00 | $170.50 | — | — | DeniedCO29 |
| Totals | $275.00 | $170.50 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-260887
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-031025 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2025-12-26: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Fail | CO29 | Received 143 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Counseling Center (9886050688). | |
| 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: Evergreen Counseling Center2025-12-26 13:05
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-18 01:28
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 143 days after the last date of service (limit 90).
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
Received after the timely-filing limit.