Claims workbench/CLM-2026-023284
Professional claim · CMS-1500 · EDI 837P

CLM-2026-023284

Pinecrest Behavioral Health, Behavioral Health. Service 2026-06-06 at telehealth (POS 02). Received 2026-06-22.

Approved
Billed
$230.00
1 line
Allowed
$142.60
contract rate applied
Plan pays
$102.60
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Anna Pena
Member ID
UHC-06834-15
Date of birth
1952-06-19
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-425379
Relationship
Self, Dallas, TX

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-9245
Coverage period
2023-12-01 to present
Deductible
$46.89 of $3,500.001%
Out-of-pocket maximum
$1,351.51 of $14,000.0010%
Copays
office $40.00, specialist $40.00, emergency $250.00
Physical therapy visits
11 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI
2968932766
Network
In network
Rendering NPI
2361489638
Location
Nashville, TN · TIN 20-1333588
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$230.00$142.60$40.00$102.60Paid
Totals$230.00$142.60$40.00$102.60
Diagnoses (ICD-10-CM)
  • 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
  • 2. F32.1 Major depressive disorder, single episode, moderate
Claim header
Patient account
PA-250615
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-035860 (verified, link confidence 0.99).
EligibilityPassActive on 2026-06-06: SELECT-EPO (EPO), effective 2023-12-01.
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Behavioral Health (2968932766).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Behavioral Health2026-06-06 13:53

    Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$230.00
Plan discount
$87.40
contracted rate
Plan paid
$102.60
You may owe
$40.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity