Claims workbench/CLM-2026-004855

Professional claim · CMS-1500 · EDI 837P

CLM-2026-004855

Lakeside Behavioral Health, Behavioral Health. Service 2025-11-25 at office (POS 11). Received 2026-05-18.

DeniedOut of network

Billed

$283.00

1 line

Allowed

$127.35

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO29, CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Willie Cole
Member ID: UHC-94020-81
Date of birth: 1985-09-21
Identity: Verified4 records, confidence 0.96
Claim record: CLMCLM-405022
Relationship: Self, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-5791
Coverage period: 2021-06-01 to present
Deductible: $481.03 of $1,500.0032%
Out-of-pocket maximum: $787.55 of $6,000.0013%
Copays: office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI: 2763853613
Network: Out of network
Rendering NPI: 8231389452
Location: Austin, TX · TIN 90-0644488
Authorisation / referral: none / REF123832

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	$283.00	$127.35	—	—	DeniedCO29
Totals						$283.00	$127.35	—	—

Diagnoses (ICD-10-CM)

1. F41.1 Generalized anxiety disorderprincipal

Claim header

Patient account: PA-389948
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-030960 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-11-25: CORE-HMO (HMO), effective 2021-06-01.
Timely filing	Fail	CO29	Received 174 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	Fail	CO204	Billing provider 2763853613 is out of network and the HMO 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Behavioral Health2025-11-25 11:58
Established patient presents with generalized anxiety disorder; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-05-18 01:53
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-18 11:01
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 174 days after the last date of service (limit 90). Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023057	2026-07-01	Heritage Primary Care Associates	$294.00	Approved
CLM-2026-023308	2026-05-01	Northgate Medical Group	$17.00	Denied
CLM-2026-023307	2026-05-01	Northgate Medical Group	$17.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity