CLM-2026-017073
Mesa Behavioral Health, Behavioral Health. Service 2026-02-08 at office (POS 11). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Ken Stephens
- Member ID
- UHC-04652-94
- Date of birth
- 2000-10-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418668
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6680
- Coverage period
- 2025-11-01 to 2026-05-16
- Deductible
- $114.88 of $1,500.008%
- Out-of-pocket maximum
- $2,663.62 of $6,000.0044%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 3652530981
- Location
- Nashville, TN · TIN 40-4103519
- Authorisation / referral
- none / REF920315
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 | 90837 | Psychotherapy, 60 minutes | 59 | 1 | 1 | $270.00 | $167.40 | — | — | Review |
| 2 | 90834 | Psychotherapy, 45 minutes | 59 | 1 | 1 | $166.00 | $102.92 | — | — | Review |
| Totals | $436.00 | $270.32 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-419987
- 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-019308 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-08: NAVIGATE-HMO (HMO), effective 2025-11-01, terms 2026-05-16. | |
| Timely filing | Pass | Received 33 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 Mesa Behavioral Health (7796147859). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Mesa Behavioral Health2026-02-08 10:58
Follow-up for post-traumatic stress disorder, unspecified. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-03-13 04:54
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-13 12:43
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-419987.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Bundled code pair; modifier 59 not supported by the operative note.