Professional claim · CMS-1500 · EDI 837P
CLM-2026-006568
Sunrise Behavioral Health, Behavioral Health. Service 2026-04-29 at telehealth (POS 02). Received 2026-06-06.
Approved
Billed
$243.00
1 line
Allowed
$150.66
contract rate applied
Plan pays
$75.66
approved
Member owes
$75.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Martha Chapman
- Member ID
- UHC-82278-33
- Date of birth
- 1938-04-06
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-410437
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1683
- Coverage period
- 2021-07-01 to present
- Deductible
- $235.26 of $500.0047%
- Out-of-pocket maximum
- $141.84 of $1,500.009%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 8320321523
- Location
- Dallas, TX · TIN 81-8341944
- 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 | $243.00 | $150.66 | $75.00 | $75.66 | Paid |
| Totals | $243.00 | $150.66 | $75.00 | $75.66 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
Claim header
- Patient account
- PA-275086
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033918 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-04-29: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Pass | Received 38 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 (9180644400). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2026-04-29 17:47
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$243.00
Plan discount
$92.34
contracted rate
Plan paid
$75.66
You may owe
$75.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019569 | 2026-07-13 | Lakeside Skin Care Associates | $908.00 | Approved |
| CLM-2026-015045 | 2026-06-30 | Evergreen Family Practice | $159.00 | 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.