CLM-2026-008282
Unity Counseling Center, Behavioral Health. Service 2026-07-17 at office (POS 11). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Amber Mejia
- Member ID
- UHC-13136-66
- Date of birth
- 1953-02-17
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404595
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5583
- Coverage period
- 2022-02-01 to present
- Deductible
- $479.90 of $1,500.0032%
- Out-of-pocket maximum
- $1,700.40 of $6,000.0028%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1248359550
- Network
- In network
- Rendering NPI
- 2266114679
- Location
- Los Angeles, CA · TIN 96-0501790
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $274.00 | $169.88 | — | — | DeniedCO18 |
| Totals | $274.00 | $169.88 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-634525
- 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-017053 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-17: - (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-008281: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Counseling Center (1248359550). | |
| 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: Unity Counseling Center2026-07-17 11:53
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-30 01:17
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-008281: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008281 | 2026-07-17 | Unity Counseling Center | $274.00 | Approved |
| CLM-2026-031289 | 2026-05-28 | Mesa GI Associates | $2,521.00 | Approved |
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
Exact duplicate of an earlier submission.