CLM-2026-005752
Unity Counseling Center, Behavioral Health. Service 2026-05-22 at office (POS 11). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Bruce Garrett
- Member ID
- UHC-23825-38
- Date of birth
- 1994-08-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424695
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3665
- Coverage period
- 2022-02-01 to present
- Deductible
- $412.19 of $3,500.0012%
- Out-of-pocket maximum
- $260.83 of $10,500.002%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1248359550
- Network
- In network
- Rendering NPI
- 3882178643
- Location
- Los Angeles, CA · TIN 96-0501790
- 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 | $417.00 | $258.54 | — | — | DeniedCO18 |
| Totals | $417.00 | $258.54 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-321310
- 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-028226 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-22: MEDICARE-ADV-A (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005751: 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 Unity Counseling Center (1248359550). | |
| 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: Unity Counseling Center2026-05-22 10:02
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-20 02:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-005751: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023861 | 2026-06-13 | Lakeside Orthopedic Specialists | $28,077.00 | Needs review |
| CLM-2026-005751 | 2026-05-22 | Unity Counseling Center | $417.00 | Approved |
| CLM-2026-024149 | 2026-04-25 | Evergreen Family Practice | $21.00 | 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.