Professional claim · CMS-1500 · Provider portal
CLM-2026-004398
Mesa Behavioral Health, Behavioral Health. Service 2026-03-10 at office (POS 11). Received 2026-03-20.
Billed
$171.00
1 line
Allowed
$106.02
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Keith Dixon
- Member ID
- UHC-86166-19
- Date of birth
- 2004-09-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406883
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9351
- Coverage period
- 2023-09-01 to present
- Deductible
- $3,094.88 of $3,500.0088%
- Out-of-pocket maximum
- $1,861.50 of $7,000.0027%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 8169136156
- Location
- Nashville, TN · TIN 40-4103519
- 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 | $171.00 | $106.02 | — | — | PendedIDQ |
| Totals | $171.00 | $106.02 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
Claim header
- Patient account
- PA-658083
- 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 | Fail | IDQ | Member record is in open steward case CASE-002271; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-03-10: NULL (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 10 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 Mesa Behavioral Health (7796147859). | |
| 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Behavioral Health2026-03-10 12:20
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002271; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.