CLM-2026-023109
Sunrise Counseling Center, Behavioral Health. Service 2025-12-18 at office (POS 11). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Wayne Jackson
- Member ID
- UHC-06505-43
- Date of birth
- 1952-12-22
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-415322
- Relationship
- Child, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8649
- Coverage period
- 2023-07-01 to present
- Deductible
- $313.00 of $1,500.0021%
- Out-of-pocket maximum
- $826.55 of $3,000.0028%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 6023584132
- Location
- Miami, FL · TIN 80-4501911
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $184.00 | $114.08 | $60.00 | $54.08 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1,2 | $189.00 | $117.18 | $0.00 | $117.18 | Paid |
| Totals | $373.00 | $231.26 | $60.00 | $171.26 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-899476
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003709 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-18: - (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 25 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 Counseling Center (6738075996). | |
| 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 Counseling Center2025-12-18 11:03
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002489 | 2025-12-22 | Riverside Orthopedic Specialists | $5,697.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.