CLM-2026-018228
Sunrise Counseling Center, Behavioral Health. Service 2026-06-19 at office (POS 11). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Danielle Cruz
- Member ID
- UHC-42973-31
- Date of birth
- 1946-12-22
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-431957
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0116
- Coverage period
- 2021-03-01 to 2026-02-24
- Deductible
- $94.41 of $500.0019%
- Out-of-pocket maximum
- $132.24 of $1,500.009%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 4614853305
- Location
- Miami, FL · TIN 80-4501911
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $360.00 | $223.20 | — | — | DeniedCO27 |
| Totals | $360.00 | $223.20 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-704416
- 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-013819 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-19 is after coverage terminated on 2026-02-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Counseling Center2026-06-19 10:11
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-25 05:53
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-25 15:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-19 is after coverage terminated on 2026-02-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012802 | 2026-01-31 | Sunrise Orthopedic Specialists | $221.00 | Approved |
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.