Professional claim · CMS-1500 · Paper
CLM-2026-018316
Summit Counseling Center, Behavioral Health. Service 2026-08-13 at telehealth (POS 02). Received 2026-08-25.
Approved
Billed
$271.00
1 line
Allowed
$168.02
contract rate applied
Plan pays
$128.02
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Charles Hayes
- Member ID
- UHC-18806-91
- Date of birth
- 1979-05-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413669
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3956
- Coverage period
- 2023-09-01 to present
- Deductible
- $353.42 of $2,500.0014%
- Out-of-pocket maximum
- $3,304.44 of $7,500.0044%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4710277862
- Network
- In network
- Rendering NPI
- 5220390350
- Location
- Denver, CO · TIN 87-9149248
- Authorisation / referral
- none / REF641445
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 | $271.00 | $168.02 | $40.00 | $128.02 | Paid |
| Totals | $271.00 | $168.02 | $40.00 | $128.02 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
Claim header
- Patient account
- PA-151996
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006483 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-13: NAVIGATE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Pass | Received 12 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 Summit Counseling Center (4710277862). | |
| 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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Counseling Center2026-08-13 10:09
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$271.00
Plan discount
$102.98
contracted rate
Plan paid
$128.02
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029155 | 2025-12-22 | Sunrise Behavioral Health | $518.00 | 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.