CLM-2026-015885
Sunrise Behavioral Health, Behavioral Health. Service 2026-07-08 at office (POS 11). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- James Ramirez
- Member ID
- UHC-84711-77
- Date of birth
- 2000-11-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408655
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9337
- Coverage period
- 2023-10-01 to 2026-04-17
- Deductible
- $1,121.70 of $1,500.0075%
- Out-of-pocket maximum
- $754.03 of $3,000.0025%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3996953287
- Location
- Denver, CO · TIN 34-6918677
- 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 | $436.00 | $270.32 | — | — | DeniedCO27 |
| 2 | 90837 | Psychotherapy, 60 minutes | 25 | 1 | 2 | $213.00 | $132.06 | — | — | DeniedCO27 |
| Totals | $649.00 | $402.38 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-729797
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003093 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-08 is after coverage terminated on 2026-04-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 Sunrise Behavioral Health (2247079397). | |
| 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: Sunrise Behavioral Health2026-07-08 10:17
Follow-up for post-traumatic stress disorder, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-18 00:09
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-08 is after coverage terminated on 2026-04-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006722 | 2026-07-27 | Pinecrest Primary Care Associates | $38.00 | Denied |
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
Service after coverage termination.