CLM-2026-020451
Heritage Behavioral Health, Behavioral Health. Service 2026-02-27 at telehealth (POS 02). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Sean Dixon
- Member ID
- UHC-62395-04
- Date of birth
- 2000-10-04
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-417926
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3261
- Coverage period
- 2022-02-01 to 2026-03-25
- Deductible
- $1,136.74 of $1,500.0076%
- Out-of-pocket maximum
- $561.62 of $3,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 4195074651
- Location
- Minneapolis, MN · TIN 71-8171673
- Authorisation / referral
- none / REF108784
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 | $312.00 | $193.44 | — | — | DeniedCO18 |
| Totals | $312.00 | $193.44 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-663294
- 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-000059 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-27: NAVIGATE-HMO (HMO), effective 2022-02-01, terms 2026-03-25. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-020450: 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 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 Health2026-02-27 18:11
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-08 01:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-08 12:19
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 13:43Duplicate check: Exact duplicate of CLM-2026-020450: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001048 | 2026-05-30 | Heritage GI Associates | $219.00 | Denied |
| CLM-2026-033078 | 2026-03-29 | Sunrise Dermatology Clinic | $407.00 | Denied |
| CLM-2026-020450 | 2026-02-27 | Heritage Behavioral Health | $312.00 | 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.