Claims workbench/CLM-2026-016510
Professional claim · CMS-1500 · EDI 837P

CLM-2026-016510

Heritage Behavioral Health, Behavioral Health. Service 2026-03-01 at office (POS 11). Received 2026-04-13.

Approved
Billed
$280.00
1 line
Allowed
$173.60
contract rate applied
Plan pays
$113.60
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
Sarah Hudson
Member ID
UHC-43359-39
Date of birth
2008-11-07
Identity
Verified2 records, confidence 0.98
Claim record
CLMCLM-408150
Relationship
Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-7532
Coverage period
2022-04-01 to present
Deductible
$265.16 of $500.0053%
Out-of-pocket maximum
$57.73 of $1,500.004%
Copays
office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits
15 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI
3499047843
Network
In network
Rendering NPI
2236286607
Location
Minneapolis, MN · TIN 71-8171673
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190791Psychiatric diagnostic evaluation—11$280.00$173.60$60.00$113.60Paid
Totals$280.00$173.60$60.00$113.60
Diagnoses (ICD-10-CM)
  • 1. F32.1 Major depressive disorder, single episode, moderateprincipal
Claim header
Patient account
PA-530619
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

CheckResultCodeDetail
Member identityPassAttached to MBR-025560 (verified, link confidence 0.98).
EligibilityPassActive on 2026-03-01: NULL (PPO), effective 2022-04-01.
Timely filingPassReceived 43 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Behavioral Health (3499047843).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Heritage Behavioral Health2026-03-01 10:40

    Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$280.00
Plan discount
$106.40
contracted rate
Plan paid
$113.60
You may owe
$60.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity