CLM-2026-006386
Evergreen Counseling Center, Behavioral Health. Service 2026-09-27 at office (POS 11). Received 2026-10-11.
Member
Resolved through the identity graph
- Member
- Zachary Marshall
- Member ID
- UHC-03354-04
- Date of birth
- 2001-11-21
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-420106
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-9656
- Coverage period
- 2022-11-01 to present
- Deductible
- $778.13 of $1,000.0078%
- Out-of-pocket maximum
- $1,196.13 of $3,000.0040%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 2348930449
- Location
- Los Angeles, CA · TIN 43-3815206
- 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 | $394.00 | $244.28 | $60.00 | $184.28 | Paid |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1,2 | $209.00 | $129.58 | $0.00 | $129.58 | Paid |
| Totals | $603.00 | $373.86 | $60.00 | $313.86 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-359965
- 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-003636 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-27: UNKNOWN (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 14 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 Evergreen Counseling Center (9886050688). | |
| 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: Evergreen Counseling Center2026-09-27 10:06
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
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
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
Clean claim, priced at contract rate.