CLM-2026-022228
Sunrise Behavioral Health, Behavioral Health. Service 2026-03-12 at telehealth (POS 02). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Susan Ward
- Member ID
- UHC-82540-45
- Date of birth
- 1976-10-13
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-426781
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0434
- Coverage period
- 2024-04-01 to 2026-02-16
- Deductible
- $305.57 of $500.0061%
- Out-of-pocket maximum
- $894.62 of $2,000.0045%
- Copays
- office $20.00, 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
- 5881664424
- Location
- Denver, CO · TIN 34-6918677
- Authorisation / referral
- none / REF779479
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 | $317.00 | $196.54 | — | — | DeniedCO27 |
| Totals | $317.00 | $196.54 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-832116
- 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-000634 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-12 is after coverage terminated on 2026-02-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2026-03-12 12:06
Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-12 05:02
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-12 is after coverage terminated on 2026-02-16.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015960 | 2026-08-28 | Unity Internal Medicine Associates | $188.00 | Denied |
| CLM-2026-000914 | 2025-12-23 | Sunrise Dermatology Clinic | $614.00 | 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
Service after coverage termination.