CLM-2026-019327
Unity Counseling Center, Behavioral Health. Service 2026-09-21 at office (POS 11). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Nicholas Le
- Member ID
- UHC-49251-67
- Date of birth
- 1977-05-15
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427165
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3496
- Coverage period
- 2023-06-01 to present
- Deductible
- $80.32 of $500.0016%
- Out-of-pocket maximum
- $354.34 of $1,000.0035%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1248359550
- Network
- In network
- Rendering NPI
- 2470668965
- Location
- Los Angeles, CA · TIN 96-0501790
- Authorisation / referral
- none / REF453976
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 | $378.00 | $234.36 | — | — | Review |
| Totals | $378.00 | $234.36 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-297535
- 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-040944 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-21: CORE-HMO (HMO), effective 2023-06-01. | |
| Timely filing | Pass | Received 3 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 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 | Review | CO16 | Documentation incomplete: “Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medicat”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Counseling Center2026-09-21 13:01
Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-24 05:27
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-24 17:30
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medicat”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.