CLM-2026-022089
Pinecrest Behavioral Health, Behavioral Health. Service 2026-08-20 at office (POS 11). Received 2026-10-07.
Member
Resolved through the identity graph
- Member
- Jacqueline Davis
- Member ID
- UHC-40454-55
- Date of birth
- 2003-05-23
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409107
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4104
- Coverage period
- 2025-07-01 to present
- Deductible
- $424.11 of $1,000.0042%
- Out-of-pocket maximum
- $159.93 of $2,000.008%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 4346942541
- Location
- Nashville, TN · TIN 20-1333588
- Authorisation / referral
- none / REF806342
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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $262.00 | $162.44 | — | — | DeniedCO18 |
| Totals | $262.00 | $162.44 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-736967
- 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-039565 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: CORE-HMO (HMO), effective 2025-07-01. | |
| Timely filing | Pass | Received 48 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-022088: 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 Pinecrest Behavioral Health (2968932766). | |
| 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: Pinecrest Behavioral Health2026-08-20 17:56
Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-07 01:18
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-022088: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022088 | 2026-08-20 | Pinecrest Behavioral Health | $262.00 | 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.