CLM-2026-011428
Unity Counseling Center, Behavioral Health. Service 2026-02-20 at office (POS 11). Received 2026-03-06.
Member
Resolved through the identity graph
- Member
- Kenneth Reynolds
- Member ID
- UHC-25022-82
- Date of birth
- 1975-11-04
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-400271
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8555
- Coverage period
- 2024-01-01 to 2026-01-17
- Deductible
- $208.96 of $500.0042%
- Out-of-pocket maximum
- $429.84 of $1,500.0029%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1248359550
- Network
- In network
- Rendering NPI
- 2126473422
- 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 | $196.00 | $121.52 | — | — | DeniedCO27 |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $209.00 | $129.58 | — | — | DeniedCO27 |
| Totals | $405.00 | $251.10 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-295942
- 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-006118 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-20 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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 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 Center2026-02-20 09:13
Established patient presents with adhd, combined type; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-06 02:22
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-20 is after coverage terminated on 2026-01-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029818 | 2026-01-15 | Summit Regional Medical Center | $2,387.00 | 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
Service after coverage termination.