CLM-2026-012516
Sunrise Counseling Center, Behavioral Health. Service 2025-12-09 at office (POS 11). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Frank Guzman
- Member ID
- UHC-66444-28
- Date of birth
- 2006-10-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-406340
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6059
- Coverage period
- 2025-04-01 to present
- Deductible
- $591.05 of $1,500.0039%
- Out-of-pocket maximum
- $597.46 of $3,000.0020%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 8053423587
- Location
- Miami, FL · TIN 80-4501911
- Authorisation / referral
- none / REF437001
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 | $313.00 | $194.06 | — | — | DeniedCO29 |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 2 | $240.00 | $148.80 | — | — | DeniedCO29 |
| Totals | $553.00 | $342.86 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-284269
- 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-029781 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-09: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Fail | CO29 | Received 150 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 Sunrise Counseling Center (6738075996). | |
| 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: Sunrise Counseling Center2025-12-09 12:05
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-08 06:06
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 150 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002827 | 2026-09-16 | Valley Skin Care Associates | $170.00 | Denied |
| CLM-2026-008286 | 2026-09-14 | Sunrise Clinical Laboratories | $114.00 | Approved |
| CLM-2026-006526 | 2026-05-15 | Meadow Heart Institute | $659.00 | 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.