CLM-2026-006592
Lakeside Behavioral Health, Behavioral Health. Service 2026-01-06 at office (POS 11). Received 2026-02-14.
Member
Resolved through the identity graph
- Member
- Riley Judith
- Member ID
- none on golden record
- Date of birth
- 1985-11-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-405534
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 2150447128
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF404461
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 | $455.00 | $204.75 | — | — | PendedN30 |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $162.00 | $72.90 | — | — | PendedN30 |
| 3 | 90837 | Psychotherapy, 60 minutes | 25 | 1 | 2 | $212.00 | $95.40 | — | — | PendedN30 |
| Totals | $829.00 | $373.05 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-451077
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013119 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 39 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Lakeside Behavioral Health2026-01-06 11:05
Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-14 05:40
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-14 17:58
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
No out-of-network benefit on this plan.