CLM-2026-016745
Sunrise Behavioral Health, Behavioral Health. Service 2026-03-22 at telehealth (POS 02). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Walter Espinoza
- Member ID
- UHC-40017-55
- Date of birth
- 1976-05-06
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-405431
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1008
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,727.31 of $2,500.0069%
- Out-of-pocket maximum
- $1,678.90 of $5,000.0034%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3697601573
- Location
- Denver, CO · TIN 34-6918677
- Authorisation / referral
- none / REF472668
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $216.00 | $133.92 | $75.00 | $58.92 | Paid |
| Totals | $216.00 | $133.92 | $75.00 | $58.92 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-135351
- 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-028988 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-22: NAVIGATE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 42 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 Health2026-03-22 14:23
Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.
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-2026-011275 | 2026-07-31 | Summit Heart Institute | $618.00 | Approved |
| CLM-2026-006703 | 2026-05-21 | Heritage Medical Group | $187.00 | Denied |
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.