CLM-2026-004836
Lakeside Behavioral Health, Behavioral Health. Service 2026-05-27 at office (POS 11). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Jordan Fowler
- Member ID
- UHC-84332-87
- Date of birth
- 1992-07-25
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-409909
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2959
- Coverage period
- 2023-12-01 to present
- Deductible
- $2,410.84 of $3,500.0069%
- Out-of-pocket maximum
- $1,867.50 of $7,000.0027%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 5773681551
- Location
- Austin, TX · TIN 90-0644488
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $201.00 | $90.45 | — | — | DeniedCO204 |
| Totals | $201.00 | $90.45 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-809733
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003834 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-27: SELECT-EPO (EPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 18 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 | Fail | CO204 | Billing provider 2763853613 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Lakeside Behavioral Health2026-05-27 14:54
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-14 04:07
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-14 15:58
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2763853613 is out of network and the EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003706 | 2026-09-15 | Mesa Diabetes Center | $578.00 | Needs review |
| CLM-2026-010292 | 2026-04-19 | Desert Internal Medicine Associates | $52.00 | 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
No out-of-network benefit on this plan.