CLM-2026-017964
Evergreen Counseling Center, Behavioral Health. Service 2026-08-21 at telehealth (POS 02). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Robert Perkins
- Member ID
- UHC-38217-24
- Date of birth
- 1968-11-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404760
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3467
- Coverage period
- 2022-07-01 to 2026-05-11
- Deductible
- $1,272.29 of $2,500.0051%
- Out-of-pocket maximum
- $3,619.38 of $10,000.0036%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 7159286989
- Location
- Los Angeles, CA · TIN 43-3815206
- 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 | $258.00 | $159.96 | — | — | DeniedCO27 |
| Totals | $258.00 | $159.96 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-533371
- 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-033903 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-21 is after coverage terminated on 2026-05-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 43 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 Evergreen Counseling Center (9886050688). | |
| 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: Evergreen Counseling Center2026-08-21 15:57
Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-03 00:58
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-21 is after coverage terminated on 2026-05-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006425 | 2026-09-23 | Cornerstone Regional Medical Center | $365.00 | Denied |
| CLM-2026-005199 | 2026-06-07 | Mesa GI Associates | $298.00 | Denied |
| CLM-2026-003541 | 2026-05-17 | Meadow Clinical Laboratories | $37.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.