Professional claim · CMS-1500 · EDI 837P
CLM-2026-012831
Northgate Counseling Center, Behavioral Health. Service 2026-03-05 at office (POS 11). Received 2026-04-12.
Approved
Billed
$430.00
1 line
Allowed
$266.60
contract rate applied
Plan pays
$206.60
approved
Member owes
$60.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Barbara Ruiz
- Member ID
- UHC-10719-99
- Date of birth
- 1989-09-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401466
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5251
- Coverage period
- 2025-09-01 to present
- Deductible
- $776.23 of $3,500.0022%
- Out-of-pocket maximum
- $6,390.36 of $14,000.0046%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4860306727
- Network
- In network
- Rendering NPI
- 2327635175
- Location
- Austin, TX · TIN 78-2836028
- 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 | $430.00 | $266.60 | $60.00 | $206.60 | Paid |
| Totals | $430.00 | $266.60 | $60.00 | $206.60 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
Claim header
- Patient account
- PA-949857
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000222 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-05: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 38 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 Northgate Counseling Center (4860306727). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Counseling Center2026-03-05 16:33
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$430.00
Plan discount
$163.40
contracted rate
Plan paid
$206.60
You may owe
$60.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016231 | 2026-03-16 | Summit Endocrine Associates | $466.00 | Approved |
| CLM-2026-023404 | 2026-02-03 | Cornerstone Reference Lab | $169.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.