Professional claim · CMS-1500 · EDI 837P
CLM-2026-005998
Sunrise Behavioral Health, Behavioral Health. Service 2026-05-02 at telehealth (POS 02). Received 2026-06-11.
Approved
Billed
$291.00
1 line
Allowed
$180.42
contract rate applied
Plan pays
$105.42
approved
Member owes
$75.00
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
- Mark Arnold
- Member ID
- UHC-13835-02
- Date of birth
- 2004-12-05
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-413593
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1137
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,585.62 of $2,500.0063%
- Out-of-pocket maximum
- $1,422.50 of $7,500.0019%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3898390406
- Location
- Denver, CO · TIN 34-6918677
- Authorisation / referral
- none / REF339885
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 | $291.00 | $180.42 | $75.00 | $105.42 | Paid |
| Totals | $291.00 | $180.42 | $75.00 | $105.42 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
Claim header
- Patient account
- PA-333756
- 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-034505 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-05-02: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 40 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 Behavioral Health (2247079397). | |
| 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 Behavioral Health2026-05-02 14:03
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$291.00
Plan discount
$110.58
contracted rate
Plan paid
$105.42
You may owe
$75.00
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-2026-012194 | 2026-08-14 | Meadow Family Practice | $182.00 | Approved |
| CLM-2026-025344 | 2026-05-26 | Summit Community Hospital | $2,556.00 | 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.