Professional claim · CMS-1500 · EDI 837P
CLM-2026-005092
Sunrise Counseling Center, Behavioral Health. Service 2025-12-28 at office (POS 11). Received 2026-01-01.
Approved
Billed
$413.00
1 line
Allowed
$256.06
contract rate applied
Plan pays
$196.06
approved
Member owes
$60.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Yuki Hoffman
- Member ID
- UHC-91732-54
- Date of birth
- 1940-03-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412667
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0969
- Coverage period
- 2022-09-01 to present
- Deductible
- $2,932.33 of $3,500.0084%
- Out-of-pocket maximum
- $493.65 of $7,000.007%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 4422197804
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $413.00 | $256.06 | $60.00 | $196.06 | Paid |
| Totals | $413.00 | $256.06 | $60.00 | $196.06 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
Claim header
- Patient account
- PA-287294
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000288 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-28: MEDICARE-ADV-B (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 4 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 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Counseling Center2025-12-28 11:56
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$413.00
Plan discount
$156.94
contracted rate
Plan paid
$196.06
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020142 | 2026-07-24 | Cornerstone Family Practice | $337.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
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.