Professional claim · CMS-1500 · Paper
CLM-2026-023494
Heritage Behavioral Health, Behavioral Health. Service 2025-12-07 at office (POS 11). Received 2026-01-21.
Approved
Billed
$525.00
2 lines
Allowed
$325.50
contract rate applied
Plan pays
$275.50
approved
Member owes
$50.00
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
- Santiago Stone
- Member ID
- UHC-50353-26
- Date of birth
- 2008-06-10
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-429113
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7005
- Coverage period
- 2022-12-01 to 2026-03-14
- Deductible
- $279.24 of $500.0056%
- Out-of-pocket maximum
- $84.82 of $1,000.008%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 8081905985
- Location
- Minneapolis, MN · TIN 71-8171673
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $316.00 | $195.92 | $50.00 | $145.92 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $209.00 | $129.58 | $0.00 | $129.58 | Paid |
| Totals | $525.00 | $325.50 | $50.00 | $275.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
Claim header
- Patient account
- PA-262395
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006505 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-07: CHOICE-PLUS-PPO (PPO), effective 2022-12-01, terms 2026-03-14. | |
| Timely filing | Pass | Received 45 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 Heritage Behavioral Health (3499047843). | |
| 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. |
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: Heritage Behavioral Health2025-12-07 12:47
Patient seen for adhd, combined type.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$525.00
Plan discount
$199.50
contracted rate
Plan paid
$275.50
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026638 | 2025-12-09 | Desert Clinical Laboratories | $69.00 | Approved |
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.