Professional claim · CMS-1500 · Provider portal
CLM-2026-021664
Sunrise Behavioral Health, Behavioral Health. Service 2026-09-03 at office (POS 11). Received 2026-09-22.
Approved
Billed
$807.00
3 lines
Allowed
$500.34
contract rate applied
Plan pays
$460.34
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Nathan Powell
- Member ID
- UHC-58381-41
- Date of birth
- 1989-03-17
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-406292
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6217
- Coverage period
- 2024-06-01 to present
- Deductible
- $572.34 of $1,000.0057%
- Out-of-pocket maximum
- $1,138.67 of $4,000.0028%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3898348636
- Location
- Denver, CO · TIN 34-6918677
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $291.00 | $180.42 | $40.00 | $140.42 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 2 | $230.00 | $142.60 | $0.00 | $142.60 | Paid |
| 3 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $286.00 | $177.32 | $0.00 | $177.32 | Paid |
| Totals | $807.00 | $500.34 | $40.00 | $460.34 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
Claim header
- Patient account
- PA-384677
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-027531 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-03: MEDICARE-ADV-B (MA), effective 2024-06-01. | |
| Timely filing | Pass | Received 19 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 Sunrise Behavioral Health (2247079397). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2026-09-03 09:12
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$807.00
Plan discount
$306.66
contracted rate
Plan paid
$460.34
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012078 | 2026-07-07 | Sunrise Digestive Health Center | $4,671.00 | Approved |
| CLM-2026-012212 | 2026-06-14 | Desert Imaging Center | $1,527.00 | Approved |
| CLM-2026-029952 | 2026-03-15 | Valley Community Hospital | $2,655.00 | Needs review |
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.