CLM-2026-013939
Summit Counseling Center, Behavioral Health. Service 2026-08-25 at office (POS 11). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Victoria Ross
- Member ID
- UHC-40023-82
- Date of birth
- 1978-06-16
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-412242
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5900
- Coverage period
- 2021-01-01 to present
- Deductible
- $32.75 of $1,500.002%
- Out-of-pocket maximum
- $1,252.21 of $3,000.0042%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4710277862
- Network
- In network
- Rendering NPI
- 3589976463
- 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 | $345.00 | $213.90 | $75.00 | $138.90 | Paid |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $256.00 | $158.72 | $0.00 | $158.72 | Paid |
| Totals | $601.00 | $372.62 | $75.00 | $297.62 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-854929
- 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-007791 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-25: MEDICARE-ADV-A (MA), effective 2021-01-01. | |
| Timely filing | Pass | Received 36 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 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 Center2026-08-25 14:58
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
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-2026-008858 | 2026-02-21 | Canyon Cardiovascular Associates | $231.00 | Approved |
| CLM-2026-001904 | 2026-02-10 | Heritage Orthopedic Specialists | $237.00 | Approved |
| CLM-2026-008050 | 2025-12-31 | Pinecrest GI Associates | $2,690.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.