CLM-2026-004805
Sunrise Counseling Center, Behavioral Health. Service 2026-07-11 at telehealth (POS 02). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Austin Soto
- Member ID
- UHC-72765-50
- Date of birth
- 1976-02-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418929
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2623
- Coverage period
- 2025-04-01 to present
- Deductible
- $845.59 of $2,500.0034%
- Out-of-pocket maximum
- $631.89 of $10,000.006%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 8033567388
- Location
- Miami, FL · TIN 80-4501911
- 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 | $222.00 | $137.64 | — | — | DeniedCO18 |
| Totals | $222.00 | $137.64 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-946302
- 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-042206 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-11: OPTIONS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 57 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004804: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Counseling Center (6738075996). | |
| 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: Sunrise Counseling Center2026-07-11 12:40
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-06 04:31
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-06 11:40
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-004804: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020269 | 2026-07-28 | Evergreen Family Practice | $238.00 | Approved |
| CLM-2026-004804 | 2026-07-11 | Sunrise Counseling Center | $222.00 | Approved |
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
Exact duplicate of an earlier submission.