CLM-2026-019959
Heritage Behavioral Health, Behavioral Health. Service 2025-10-15 at office (POS 11). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Gabriel Nguyen
- Member ID
- UHC-08946-13
- Date of birth
- 1949-04-25
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-411549
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7818
- Coverage period
- 2024-08-01 to present
- Deductible
- $267.71 of $2,500.0011%
- Out-of-pocket maximum
- $2,488.27 of $5,000.0050%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 4654041431
- Location
- Minneapolis, MN · TIN 71-8171673
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $170.00 | $105.40 | — | — | DeniedCO29 |
| 2 | 90837 | Psychotherapy, 60 minutes | 25 | 1 | 1 | $213.00 | $132.06 | — | — | DeniedCO29 |
| Totals | $383.00 | $237.46 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- Patient account
- PA-154456
- 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-003510 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-10-15: CHOICE-PLUS-PPO (PPO), effective 2024-08-01. | |
| Timely filing | Fail | CO29 | Received 178 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Behavioral Health (3499047843). | |
| 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: Heritage Behavioral Health2025-10-15 16:39
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-11 04:03
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-11 13:22
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 178 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000085 | 2025-12-25 | Lakeside Dermatology Clinic | $620.00 | 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
Received after the timely-filing limit.