Professional claim · CMS-1500 · EDI 837P
CLM-2026-019313
Sunrise Counseling Center, Behavioral Health. Service 2026-06-21 at office (POS 11). Received 2026-07-05.
Approved
Billed
$805.00
3 lines
Allowed
$499.10
contract rate applied
Plan pays
$449.10
approved
Member owes
$50.00
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
- Thomas Welch
- Member ID
- UHC-45658-13
- Date of birth
- 2007-02-15
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-409050
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3343
- Coverage period
- 2023-07-01 to present
- Deductible
- $252.54 of $1,500.0017%
- Out-of-pocket maximum
- $2,298.10 of $6,000.0038%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 3639199256
- 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 | $405.00 | $251.10 | $50.00 | $201.10 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | 25 | 1 | 1,2 | $196.00 | $121.52 | $0.00 | $121.52 | Paid |
| 3 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $204.00 | $126.48 | $0.00 | $126.48 | Paid |
| Totals | $805.00 | $499.10 | $50.00 | $449.10 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
Claim header
- Patient account
- PA-181861
- 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-026980 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-21: OPTIONS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 14 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. |
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: Sunrise Counseling Center2026-06-21 18:08
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$805.00
Plan discount
$305.90
contracted rate
Plan paid
$449.10
You may owe
$50.00
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-2026-003230 | 2026-03-23 | Valley Skin Care Associates | $873.00 | Approved |
| CLM-2026-002566 | 2026-04-14 | Summit Primary Care Associates | $480.00 | 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.