CLM-2026-006362
Sunrise Counseling Center, Behavioral Health. Service 2026-05-27 at telehealth (POS 02). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Hiroshi Ortega
- Member ID
- UHC-36461-06
- Date of birth
- 1979-11-11
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-400480
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1116
- Coverage period
- 2025-05-01 to present
- Deductible
- $365.38 of $500.0073%
- Out-of-pocket maximum
- $625.30 of $2,000.0031%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 7668656581
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $291.00 | $180.42 | $40.00 | $140.42 | Paid |
| Totals | $291.00 | $180.42 | $40.00 | $140.42 | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-835425
- 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-019889 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-27: MEDICARE-ADV-B (MA), effective 2025-05-01. | |
| Timely filing | Pass | Received 36 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Counseling Center2026-05-27 17:16
Patient seen for major depressive disorder, single episode, moderate. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-02 03:11
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-02 16:26
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-835425.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
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-2026-027831 | 2026-08-11 | Harbor Medical Group | $352.00 | Approved |
| CLM-2026-011639 | 2026-06-15 | Mesa Reference Lab | $88.00 | Approved |
| CLM-2026-005919 | 2026-03-10 | Pinecrest Behavioral Health | $288.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.