Professional claim · CMS-1500 · EDI 837P
CLM-2026-021536
Evergreen Counseling Center, Behavioral Health. Service 2026-03-16 at telehealth (POS 02). Received 2026-04-06.
Approved
Billed
$304.00
1 line
Allowed
$188.48
contract rate applied
Plan pays
$113.48
approved
Member owes
$75.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- George Knight
- Member ID
- UHC-75257-74
- Date of birth
- 1998-04-09
- Identity
- Verified3 records, confidence 0.86
- Claim record
- CLMCLM-402751
- Relationship
- Spouse, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-9144
- Coverage period
- 2021-07-01 to present
- Deductible
- $633.07 of $1,500.0042%
- Out-of-pocket maximum
- $480.16 of $6,000.008%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 8236767686
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $304.00 | $188.48 | $75.00 | $113.48 | Paid |
| Totals | $304.00 | $188.48 | $75.00 | $113.48 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
Claim header
- Patient account
- PA-783203
- 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-001992 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2026-03-16: NULL (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 21 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 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Counseling Center2026-03-16 09:37
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$304.00
Plan discount
$115.52
contracted rate
Plan paid
$113.48
You may owe
$75.00
copay, deductible and coinsurance
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
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.