CLM-2026-022442
Unity Counseling Center, Behavioral Health. Service 2026-08-20 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Helen Dominguez
- Member ID
- UHC-96057-46
- Date of birth
- 2000-05-20
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-420433
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4144
- Coverage period
- 2025-08-01 to 2026-08-04
- Deductible
- $1,552.85 of $2,500.0062%
- Out-of-pocket maximum
- $772.10 of $7,500.0010%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6412199344
- Network
- In network
- Rendering NPI
- 4505305159
- Location
- Denver, CO · TIN 61-7972607
- Authorisation / referral
- none / REF445402
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 | $399.00 | $247.38 | — | — | DeniedCO27 |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 2 | $292.00 | $181.04 | — | — | DeniedCO27 |
| Totals | $691.00 | $428.42 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- Patient account
- PA-926664
- 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-002246 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-20 is after coverage terminated on 2026-08-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 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 Unity Counseling Center (6412199344). | |
| 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: Unity Counseling Center2026-08-20 12:54
Established patient presents with generalized anxiety disorder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-17 00:40
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 2026-08-20 is after coverage terminated on 2026-08-04.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019584 | 2026-06-19 | Desert Primary Care Associates | $233.00 | 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
Service after coverage termination.