CLM-2026-021052
Evergreen Counseling Center, Behavioral Health. Service 2026-01-26 at office (POS 11). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Susan Mason
- Member ID
- UHC-43398-29
- Date of birth
- 1954-06-27
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-421732
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6124
- Coverage period
- 2021-07-01 to present
- Deductible
- $936.35 of $2,500.0037%
- Out-of-pocket maximum
- $1,217.13 of $10,000.0012%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 8838306362
- Location
- Los Angeles, CA · TIN 43-3815206
- 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 | $176.00 | $109.12 | — | — | DeniedCO18 |
| 2 | 90791 | Psychiatric diagnostic evaluation | 25 | 1 | 2 | $416.00 | $257.92 | — | — | DeniedCO18 |
| Totals | $592.00 | $367.04 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- Patient account
- PA-475438
- 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-015891 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-26: MEDICARE-ADV-A (MA), effective 2021-07-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-021051: 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 Evergreen Counseling Center (9886050688). | |
| 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: Evergreen Counseling Center2026-01-26 17:56
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-04 01:01
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-04 10:43
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-021051: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021051 | 2026-01-26 | Evergreen Counseling Center | $592.00 | 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.