Professional claim · CMS-1500 · EDI 837P
CLM-2026-013839
Mesa Behavioral Health, Behavioral Health. Service 2026-03-12 at office (POS 11). Received 2026-04-04.
Approved
Billed
$402.00
2 lines
Allowed
$249.24
contract rate applied
Plan pays
$174.24
approved
Member owes
$75.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Scott Schultz
- Member ID
- UHC-40594-68
- Date of birth
- 1938-06-06
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-403825
- Relationship
- Child, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0907
- Coverage period
- 2022-02-01 to present
- Deductible
- $165.35 of $1,000.0017%
- Out-of-pocket maximum
- $783.12 of $2,000.0039%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 6778893811
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $259.00 | $160.58 | $75.00 | $85.58 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $143.00 | $88.66 | $0.00 | $88.66 | Paid |
| Totals | $402.00 | $249.24 | $75.00 | $174.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
Claim header
- Patient account
- PA-613033
- 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-009986 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-12: MEDICARE-ADV-A (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 23 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) | 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: Mesa Behavioral Health2026-03-12 09:18
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$402.00
Plan discount
$152.76
contracted rate
Plan paid
$174.24
You may owe
$75.00
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-2026-000462 | 2026-03-06 | Mesa Dermatology Clinic | $190.00 | 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.