Claims workbench/CLM-2026-023386
Professional claim · CMS-1500 · Paper

CLM-2026-023386

Mesa Behavioral Health, Behavioral Health. Service 2026-02-09 at office (POS 11). Received 2026-02-26.

Approved
Billed
$397.00
1 line
Allowed
$246.14
contract rate applied
Plan pays
$186.14
approved
Member owes
$60.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Cynthia Medina
Member ID
UHC-10029-27
Date of birth
2004-08-19
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-423622
Relationship
Self, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan
UNKNOWN PPO group GRP-1206
Coverage period
2021-03-01 to present
Deductible
$1,256.10 of $3,500.0036%
Out-of-pocket maximum
$4,470.68 of $14,000.0032%
Copays
office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits
15 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI
7796147859
Network
In network
Rendering NPI
9501817933
Location
Nashville, TN · TIN 40-4103519
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190791Psychiatric diagnostic evaluation—11$397.00$246.14$60.00$186.14Paid
Totals$397.00$246.14$60.00$186.14
Diagnoses (ICD-10-CM)
  • 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
  • 2. F90.2 ADHD, combined type
Claim header
Patient account
PA-799968
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-016043 (verified, link confidence 0.99).
EligibilityPassActive on 2026-02-09: UNKNOWN (PPO), effective 2021-03-01.
Timely filingPassReceived 17 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Behavioral Health (7796147859).
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: Mesa Behavioral Health2026-02-09 12:27

    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
$397.00
Plan discount
$150.86
contracted rate
Plan paid
$186.14
You may owe
$60.00
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