Claims workbench/CLM-2026-022068
Professional claim · CMS-1500 · EDI 837P

CLM-2026-022068

Unity Counseling Center, Behavioral Health. Service 2026-03-04 at telehealth (POS 02). Received 2026-04-05.

PendedIdentity on hold: CASE-002198
Billed
$302.00
1 line
Allowed
$187.24
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Samuel Green
Member ID
UHC-81219-27
Date of birth
2005-09-27
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-420333
Relationship
Self

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-0529
Coverage period
2025-05-01 to present
Deductible
$987.35 of $1,500.0066%
Out-of-pocket maximum
$1,046.01 of $3,000.0035%
Copays
office $40.00, specialist $60.00, emergency $350.00
Physical therapy visits
16 of 20 used

Provider

Billing and rendering

Billing provider
Unity Counseling Center
Behavioral Health · taxonomy 103T00000X
NPI
1248359550
Network
In network
Rendering NPI
1478412749
Location
Los Angeles, CA · TIN 96-0501790
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$302.00$187.24——PendedIDQ
Totals$302.00$187.24——
Diagnoses (ICD-10-CM)
  • 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
  • 2. F32.1 Major depressive disorder, single episode, moderate
Claim header
Patient account
PA-396569
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002198; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-03-04: OPTIONS-PPO (PPO), effective 2025-05-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Counseling Center (1248359550).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Unity Counseling Center2026-03-04 12:53

    Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002198; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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.

Review queueMember identity