CLM-2026-011976
Mesa Behavioral Health, Behavioral Health. Service 2026-07-22 at office (POS 11). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Albert Gardner
- Member ID
- UHC-51913-36
- Date of birth
- 1993-09-01
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422341
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1201
- Coverage period
- 2021-06-01 to present
- Deductible
- $623.59 of $1,500.0042%
- Out-of-pocket maximum
- $1,648.87 of $6,000.0027%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 3044490100
- Location
- Nashville, TN · TIN 40-4103519
- 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 | 59 | 1 | 1 | $393.00 | $243.66 | — | — | Review |
| 2 | 90837 | Psychotherapy, 60 minutes | 59 | 1 | 1 | $300.00 | $186.00 | — | — | Review |
| Totals | $693.00 | $429.66 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-691107
- 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-007519 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-22: - (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 27 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 Mesa Behavioral Health (7796147859). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Mesa Behavioral Health2026-07-22 09:26
Patient seen for post-traumatic stress disorder, unspecified. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-08-18 01:05
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-18 15:05
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-691107.pdf19 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.