CLM-2026-022432
Lakeside Behavioral Health, Behavioral Health. Service 2026-09-06 at office (POS 11). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Steven Gilbert
- Member ID
- UHC-22739-27
- Date of birth
- 1963-10-24
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-409155
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5736
- Coverage period
- 2023-05-01 to present
- Deductible
- $756.44 of $1,000.0076%
- Out-of-pocket maximum
- $547.57 of $2,000.0027%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 3498180249
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF427713
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 | $297.00 | $133.65 | — | — | DeniedCO204 |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 2 | $142.00 | $63.90 | — | — | DeniedCO204 |
| Totals | $439.00 | $197.55 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-176907
- 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-002957 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-06: NAVIGATE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 38 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 | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Lakeside Behavioral Health2026-09-06 11:41
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-14 02:18
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018519 | 2026-09-25 | Riverside Community Hospital | $203.00 | Approved |
| CLM-2026-002569 | 2026-03-25 | Unity Community Hospital | $2,227.00 | Approved |
| CLM-2026-019699 | 2025-12-30 | Valley Medical Group | $2,901.00 | Needs review |
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
No out-of-network benefit on this plan.