CLM-2026-016575
Canyon Counseling Center, Behavioral Health. Service 2025-12-16 at office (POS 11). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Sharon Gomez
- Member ID
- UHC-34933-75
- Date of birth
- 1967-02-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412770
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4425
- Coverage period
- 2021-09-01 to present
- Deductible
- $642.64 of $3,500.0018%
- Out-of-pocket maximum
- $158.46 of $10,500.002%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 7754489301
- Location
- Minneapolis, MN · TIN 48-3708210
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $140.00 | $63.00 | — | — | Review |
| Totals | $140.00 | $63.00 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-326272
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001121 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-16: MEDICARE-ADV-B (MA), effective 2021-09-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-016574; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Canyon Counseling Center2025-12-16 15:44
Follow-up for adhd, combined type. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-07 04:39
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-07 17:41
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-016574.pdf1 page
Provider cover letter requesting replacement of CLM-2026-016574.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-016574; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
- AI recommendationApproved2026-10-21 14:15This is a replacement claim (frequency code 7) for an earlier claim that was approved [H1]. The provider has submitted a corrected claim with a cover letter explaining the correction [A1]. The original claim must be voided when this one adjudicates [N2]. The service is medically necessary and within the allowed limits [R-clinical_edit], [R-benefit_limit]. The provider is out-of-network, but the claim is within the auto-adjudication ceiling [R-high_dollar]. The claim is complete and has passed all other checks [R-completeness].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 78297493
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028582 | 2026-03-23 | Heritage Physical Therapy | $346.00 | Needs review |
| CLM-2026-028581 | 2026-03-23 | Lakeside Physical Therapy | $346.00 | Approved |
| CLM-2026-016574 | 2025-12-16 | Canyon Counseling Center | $140.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim (frequency code 7) for an earlier claim that was approved [H1]. The provider has submitted a corrected claim with a cover letter explaining the correction [A1]. The original claim must be voided when this one adjudicates [N2]. The service is medically necessary and within the allowed limits [R-clinical_edit], [R-benefit_limit]. The provider is out-of-network, but the claim is within the auto-adjudication ceiling [R-high_dollar]. The claim is complete and has passed all other checks [R-completeness].
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
Replacement claim supersedes the original.