CLM-2026-012054
Summit Counseling Center, Behavioral Health. Service 2026-08-03 at office (POS 11). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Janet Stone
- Member ID
- UHC-04296-62
- Date of birth
- 1994-05-27
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413963
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3052
- Coverage period
- 2024-03-01 to present
- Deductible
- $183.01 of $1,500.0012%
- Out-of-pocket maximum
- $1,081.85 of $4,500.0024%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4710277862
- Network
- In network
- Rendering NPI
- 2919869430
- Location
- Denver, CO · TIN 87-9149248
- 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 | — | 1 | 1 | $402.00 | $249.24 | — | — | DeniedCO18 |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 2 | $154.00 | $95.48 | — | — | DeniedCO18 |
| Totals | $556.00 | $344.72 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-281440
- 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-023270 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-03: - (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012053: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Center2026-08-03 09:01
Patient seen for major depressive disorder, single episode, moderate.
- SystemSystem: Claims system2026-09-19 03:43
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-19 17:53
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 13:43Duplicate check: Exact duplicate of CLM-2026-012053: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012053 | 2026-08-03 | Summit Counseling Center | $556.00 | Approved |
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
Exact duplicate of an earlier submission.