CLM-2026-022376
Summit Counseling Center, Behavioral Health. Service 2026-06-30 at office (POS 11). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Juan Franklin
- Member ID
- UHC-92188-10
- Date of birth
- 1963-03-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415466
- Relationship
- Spouse, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7403
- Coverage period
- 2022-11-01 to 2026-05-01
- Deductible
- $394.84 of $1,000.0039%
- Out-of-pocket maximum
- $1,030.00 of $4,000.0026%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4710277862
- Network
- In network
- Rendering NPI
- 8943182419
- Location
- Denver, CO · TIN 87-9149248
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $141.00 | $87.42 | — | — | DeniedCO27 |
| Totals | $141.00 | $87.42 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- Patient account
- PA-159263
- 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-029389 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-30 is after coverage terminated on 2026-05-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 26 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 Summit Counseling Center (4710277862). | |
| 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: Summit Counseling Center2026-06-30 10:31
Established patient presents with generalized anxiety disorder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-26 00:54
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 2026-06-30 is after coverage terminated on 2026-05-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004662 | 2026-09-05 | Meadow Heart Institute | $1,817.00 | Denied |
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.