CLM-2026-015181
Unity Counseling Center, Behavioral Health. Service 2026-04-24 at office (POS 11). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Rachle Scott
- Member ID
- none on golden record
- Date of birth
- 1953-01-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-410458
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-3516
- Coverage period
- 2022-09-01 to present
- Deductible
- $1,036.70 of $1,500.0069%
- Out-of-pocket maximum
- $809.16 of $3,000.0027%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6412199344
- Network
- In network
- Rendering NPI
- 1993685522
- Location
- Denver, CO · TIN 61-7972607
- 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 | $264.00 | $163.68 | — | — | PendedIDQ |
| Totals | $264.00 | $163.68 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-985990
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001188; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-04-24: OPTIONS-PPO (PPO), effective 2022-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 45 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 Unity Counseling Center (6412199344). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for major depressive disorder, single episode, moderate. Note dictated; signa”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Counseling Center2026-04-24 11:40
Patient seen for major depressive disorder, single episode, moderate. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-08 00:30
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001188; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-24: OPTIONS-PPO (PPO), effective 2022-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Patient seen for major depressive disorder, single episode, moderate. Note dictated; signa”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.