CLM-2026-012611
Canyon Counseling Center, Behavioral Health. Service 2026-03-16 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Michelle Andrews
- Member ID
- UHC-95441-15
- Date of birth
- 1993-08-24
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-416902
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0188
- Coverage period
- 2024-11-01 to present
- Deductible
- $466.22 of $3,500.0013%
- Out-of-pocket maximum
- $603.96 of $7,000.009%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 1709331304
- Location
- Minneapolis, MN · TIN 48-3708210
- Authorisation / referral
- none / REF979064
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 | $246.00 | $110.70 | — | — | DeniedCO204 |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $357.00 | $160.65 | — | — | DeniedCO204 |
| 3 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1,2 | $225.00 | $101.25 | — | — | DeniedCO204 |
| Totals | $828.00 | $372.60 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-147097
- 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-014702 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-03-16: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 4 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 | Fail | CO204 | Billing provider 1279449718 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Canyon Counseling Center2026-03-16 15:28
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-20 06:57
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 1279449718 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034215 | 2026-06-18 | Desert Clinical Laboratories | $167.00 | Approved |
| CLM-2026-003645 | 2026-04-28 | Riverside Internal Medicine Associates | $219.00 | 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
No out-of-network benefit on this plan.