Professional claim · CMS-1500 · Paper
CLM-2026-018020
Sunrise Counseling Center, Behavioral Health. Service 2026-08-04 at telehealth (POS 02). Received 2026-08-09.
Approved
Billed
$220.00
1 line
Allowed
$136.40
contract rate applied
Plan pays
$76.40
approved
Member owes
$60.00
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
- Frank Padilla
- Member ID
- UHC-18739-54
- Date of birth
- 1964-02-14
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-405258
- Relationship
- Child, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3480
- Coverage period
- 2023-06-01 to present
- Deductible
- $1,729.38 of $3,500.0049%
- Out-of-pocket maximum
- $4,676.32 of $14,000.0033%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 1527897502
- Location
- Miami, FL · TIN 80-4501911
- Authorisation / referral
- none / REF497178
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 | $220.00 | $136.40 | $60.00 | $76.40 | Paid |
| Totals | $220.00 | $136.40 | $60.00 | $76.40 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
Claim header
- Patient account
- PA-293021
- 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-019806 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-04: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 5 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 Counseling Center (6738075996). | |
| 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: Sunrise Counseling Center2026-08-04 15:11
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$220.00
Plan discount
$83.60
contracted rate
Plan paid
$76.40
You may owe
$60.00
copay, deductible and coinsurance
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-2026-018021 | 2026-08-04 | Pinecrest Behavioral Health | $220.00 | Needs review |
| CLM-2026-008010 | 2026-07-12 | Heritage Imaging Center | $374.00 | Approved |
| CLM-2026-024733 | 2026-04-24 | Riverside Orthopedic Specialists | $8,953.00 | Denied |
| CLM-2026-030057 | 2026-02-26 | Riverside Internal Medicine Associates | $222.00 | Denied |
| CLM-2026-011315 | 2026-02-09 | Heritage Medical Group | $411.00 | 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.