CLM-2026-009979
Heritage Behavioral Health, Behavioral Health. Service 2026-09-16 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Charles Edwards
- Member ID
- UHC-50789-07
- Date of birth
- 1939-11-15
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-408836
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8208
- Coverage period
- 2024-12-01 to 2026-04-23
- Deductible
- $806.59 of $3,500.0023%
- Out-of-pocket maximum
- $6,849.62 of $14,000.0049%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 9848384191
- Location
- Minneapolis, MN · TIN 71-8171673
- Authorisation / referral
- none / REF395895
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 | $279.00 | $172.98 | — | — | DeniedCO27 |
| Totals | $279.00 | $172.98 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- Patient account
- PA-391451
- 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-023974 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-16 is after coverage terminated on 2026-04-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Heritage Behavioral Health (3499047843). | |
| 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: Heritage Behavioral Health2026-09-16 17:17
Established patient presents with generalized anxiety disorder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-24 03:13
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-24 08:30
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-16 is after coverage terminated on 2026-04-23.
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
Service after coverage termination.