CLM-2026-018304
Pinecrest Behavioral Health, Behavioral Health. Service 2026-01-25 at office (POS 11). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Bruce Jensen
- Member ID
- UHC-93320-87
- Date of birth
- 1965-06-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421454
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8841
- Coverage period
- 2024-10-01 to present
- Deductible
- $93.67 of $1,500.006%
- Out-of-pocket maximum
- $1,957.34 of $6,000.0033%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 3358887263
- Location
- Nashville, TN · TIN 20-1333588
- Authorisation / referral
- none / REF536095
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 | — | 1 | 1 | $292.00 | $181.04 | $60.00 | $121.04 | Paid |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $459.00 | $284.58 | $0.00 | $284.58 | Paid |
| Totals | $751.00 | $465.62 | $60.00 | $405.62 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-208725
- 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-014734 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-25: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 27 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 Pinecrest Behavioral Health (2968932766). | |
| 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: Pinecrest Behavioral Health2026-01-25 17:28
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
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-2026-019564 | 2026-09-24 | Northgate Primary Care Associates | $209.00 | Denied |
| CLM-2026-009939 | 2026-02-09 | Northgate Medical Group | $551.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.