CLM-2026-009360
Evergreen Counseling Center, Behavioral Health. Service 2026-08-23 at office (POS 11). Received 2026-09-07.
Member
Resolved through the identity graph
- Member
- Ailce Griffin
- Member ID
- UHC-73266-95
- Date of birth
- 1973-02-01
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417528
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- - PPO group NULL
- Coverage period
- 2021-10-01 to present
- Deductible
- $550.45 of $2,500.0022%
- Out-of-pocket maximum
- $2,771.95 of $7,500.0037%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 9666509556
- 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 | $370.00 | $229.40 | $50.00 | $179.40 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $226.00 | $140.12 | $0.00 | $140.12 | Paid |
| Totals | $596.00 | $369.52 | $50.00 | $319.52 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-593140
- 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-043623 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-23: - (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 15 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 Center2026-08-23 10:59
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.