CLM-2026-019562
Sunrise Counseling Center, Behavioral Health. Service 2026-09-29 at office (POS 11). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Dylan Gomez
- Member ID
- UHC-44561-38
- Date of birth
- 1963-08-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429655
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2025-04-01 to present
- Deductible
- $674.90 of $1,000.0067%
- Out-of-pocket maximum
- $78.07 of $2,000.004%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 4187831654
- Location
- Miami, FL · TIN 80-4501911
- Authorisation / referral
- none / REF566188
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 | $391.00 | $242.42 | $50.00 | $192.42 | Paid |
| Totals | $391.00 | $242.42 | $50.00 | $192.42 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-657732
- 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-020947 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-29: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 6 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Counseling Center2026-09-29 17:17
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
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-2026-002312 | 2026-08-15 | Sunrise Behavioral Health | $395.00 | Approved |
| CLM-2026-007843 | 2026-07-24 | Pinecrest Regional Medical Center | $674.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.