CLM-2026-019210
Unity Counseling Center, Behavioral Health. Service 2026-08-15 at telehealth (POS 02). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Santiago Nunez
- Member ID
- UHC-42554-30
- Date of birth
- 1954-08-27
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-402852
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1288
- Coverage period
- 2022-07-01 to present
- Deductible
- $1,800.92 of $2,500.0072%
- Out-of-pocket maximum
- $3,603.31 of $10,000.0036%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1248359550
- Network
- In network
- Rendering NPI
- 9363814275
- Location
- Los Angeles, CA · TIN 96-0501790
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $245.00 | $151.90 | — | — | DeniedCO18 |
| Totals | $245.00 | $151.90 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-960783
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018578 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-15: NULL (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-019209: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Counseling Center (1248359550). | |
| 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: Unity Counseling Center2026-08-15 10:39
Established patient presents with adhd, combined type; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-29 00:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-29 16:33
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-019209: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019209 | 2026-08-15 | Unity Counseling Center | $245.00 | 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
Exact duplicate of an earlier submission.