CLM-2026-023679
Mesa Behavioral Health, Behavioral Health. Service 2025-12-09 at telehealth (POS 02). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- William Moreno
- Member ID
- UHC-19618-72
- Date of birth
- 1992-11-26
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-410030
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2905
- Coverage period
- 2023-01-01 to present
- Deductible
- $896.68 of $1,000.0090%
- Out-of-pocket maximum
- $446.31 of $2,000.0022%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 2620636821
- Location
- Nashville, TN · TIN 40-4103519
- Authorisation / referral
- none / REF723926
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $276.00 | $171.12 | $60.00 | $111.12 | Paid |
| Totals | $276.00 | $171.12 | $60.00 | $111.12 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-454046
- 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-003544 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-09: NAVIGATE-HMO (HMO), effective 2023-01-01. | |
| Timely filing | Pass | Received 34 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 Mesa Behavioral Health (7796147859). | |
| 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: Mesa Behavioral Health2025-12-09 16:16
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-2026-013735 | 2026-02-06 | Canyon Diagnostic Imaging | $1,677.00 | Approved |
| CLM-2026-012102 | 2026-02-02 | Heritage Behavioral Health | $309.00 | 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.