CLM-2026-018406
Lakeside Behavioral Health, Behavioral Health. Service 2026-03-04 at office (POS 11). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Virginia Medina
- Member ID
- UHC-77003-34
- Date of birth
- 2005-07-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-431621
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0963
- Coverage period
- 2021-06-01 to present
- Deductible
- $288.97 of $1,000.0029%
- Out-of-pocket maximum
- $653.22 of $3,000.0022%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 9942936581
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF751087
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 | $184.00 | $82.80 | — | — | DeniedCO204 |
| Totals | $184.00 | $82.80 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-775066
- 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-020345 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-04: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| Timely filing | Pass | Received 13 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 | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Lakeside Behavioral Health2026-03-04 09:08
Patient seen for adhd, combined type.
- SystemSystem: Claims system2026-03-17 00:42
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.