CLM-2026-020645
Lakeside Behavioral Health, Behavioral Health. Service 2026-06-12 at office (POS 11). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Eugene Hall
- Member ID
- UHC-55249-21
- Date of birth
- 1955-04-03
- Identity
- Verified4 records, confidence 0.90
- Claim record
- CLMCLM-416039
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4948
- Coverage period
- 2024-12-01 to present
- Deductible
- $440.02 of $2,500.0018%
- Out-of-pocket maximum
- $3,276.95 of $7,500.0044%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 4381254158
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF694795
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 | $200.00 | $90.00 | — | — | DeniedCO204 |
| Totals | $200.00 | $90.00 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-195585
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032975 (verified, link confidence 0.90). | |
| Eligibility | Pass | Active on 2026-06-12: NAVIGATE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 38 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 | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Lakeside Behavioral Health2026-06-12 11:37
Established patient presents with adhd, combined type; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-20 04:10
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-20 16:15
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
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
No out-of-network benefit on this plan.