CLM-2026-010319
Summit Counseling Center, Behavioral Health. Service 2025-10-10 at office (POS 11). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Patricia Robertson
- Member ID
- UHC-21505-88
- Date of birth
- 1997-07-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415144
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3561
- Coverage period
- 2024-07-01 to present
- Deductible
- $64.60 of $500.0013%
- Out-of-pocket maximum
- $680.11 of $2,000.0034%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4710277862
- Network
- In network
- Rendering NPI
- 8394859655
- Location
- Denver, CO · TIN 87-9149248
- Authorisation / referral
- none / REF795005
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 | $186.00 | $115.32 | — | — | DeniedCO29 |
| Totals | $186.00 | $115.32 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- Patient account
- PA-876038
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010953 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-10-10: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Fail | CO29 | Received 119 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Counseling Center (4710277862). | |
| 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: Summit Counseling Center2025-10-10 10:43
Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-06 06:25
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-06 17:10
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 engineDenied2026-10-22 12:44Timely filing: Received 119 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018224 | 2026-04-02 | Evergreen Primary Care Associates | $457.00 | Needs review |
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
Received after the timely-filing limit.