CLM-2026-006195
Unity Counseling Center, Behavioral Health. Service 2026-03-26 at office (POS 11). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Jeremy West
- Member ID
- UHC-33653-23
- Date of birth
- 1938-07-24
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-427296
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5449
- Coverage period
- 2023-01-01 to present
- Deductible
- $360.66 of $500.0072%
- Out-of-pocket maximum
- $957.96 of $2,000.0048%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6412199344
- Network
- In network
- Rendering NPI
- 7813857951
- Location
- Denver, CO · TIN 61-7972607
- 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 | 59 | 1 | 1 | $449.00 | $278.38 | — | — | Review |
| 2 | 90837 | Psychotherapy, 60 minutes | 59 | 1 | 2 | $263.00 | $163.06 | — | — | Review |
| Totals | $712.00 | $441.44 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-163339
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010156 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-26: MEDICARE-ADV-A (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 25 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 Unity Counseling Center (6412199344). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2026-03-26 16:38
Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-04-20 04:24
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-163339.pdf19 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.