CLM-2026-011794
Unity Counseling Center, Behavioral Health. Service 2026-04-07 at telehealth (POS 02). Received 2026-04-30.
Member
Resolved through the identity graph
- Member
- Sharon Gonzalez
- Member ID
- UHC-47471-13
- Date of birth
- 1941-05-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406636
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0904
- Coverage period
- 2021-01-01 to present
- Deductible
- $609.15 of $1,000.0061%
- Out-of-pocket maximum
- $471.31 of $2,000.0024%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6412199344
- Network
- In network
- Rendering NPI
- 6764196898
- Location
- Denver, CO · TIN 61-7972607
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $288.00 | $178.56 | $75.00 | $103.56 | Paid |
| Totals | $288.00 | $178.56 | $75.00 | $103.56 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-828959
- 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-028397 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-07: - (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 23 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 (6412199344). | |
| 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 Center2026-04-07 13:31
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011795 | 2026-04-07 | Unity Counseling Center | $288.00 | Denied |
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.