Professional claim · CMS-1500 · EDI 837P
CLM-2026-017048
Canyon Counseling Center, Behavioral Health. Service 2026-02-12 at telehealth (POS 02). Received 2026-03-14.
ApprovedOut of network
Billed
$285.00
1 line
Allowed
$128.25
contract rate applied
Plan pays
$88.25
approved
Member owes
$40.00
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
- Dylan Lynch
- Member ID
- UHC-13247-56
- Date of birth
- 1999-03-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-428811
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8168
- Coverage period
- 2024-09-01 to present
- Deductible
- $354.91 of $2,500.0014%
- Out-of-pocket maximum
- $2,956.42 of $10,000.0030%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 5331147848
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $285.00 | $128.25 | $40.00 | $88.25 | Paid |
| Totals | $285.00 | $128.25 | $40.00 | $88.25 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
Claim header
- Patient account
- PA-644708
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019643 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-12: MEDICARE-ADV-B (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 30 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 | 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. |
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: Canyon Counseling Center2026-02-12 12:45
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$285.00
Plan discount
$156.75
out-of-network allowance
Plan paid
$88.25
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012398 | 2026-06-16 | Northgate Bone and Joint Center | $31,253.00 | Needs review |
| CLM-2026-031887 | 2026-06-06 | Evergreen Family Practice | $25.00 | Approved |
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.