CLM-2026-006932
Lakeside Behavioral Health, Behavioral Health. Service 2026-05-20 at office (POS 11). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Camila Alvarado
- Member ID
- UHC-49908-53
- Date of birth
- 1977-07-19
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-404143
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0380
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,121.50 of $2,500.0045%
- Out-of-pocket maximum
- $1,856.06 of $5,000.0037%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 6196724333
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF230090
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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $207.00 | $93.15 | — | — | DeniedCO204 |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $401.00 | $180.45 | — | — | DeniedCO204 |
| Totals | $608.00 | $273.60 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- Patient account
- PA-284542
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015452 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-20: CORE-HMO (HMO), effective 2021-09-01. | |
| Timely filing | Pass | Received 45 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 | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Health2026-05-20 13:49
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-04 05:49
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.