CLM-2026-023822
Canyon Counseling Center, Behavioral Health. Service 2025-09-22 at office (POS 11). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Santiago Aguilar
- Member ID
- UHC-15363-06
- Date of birth
- 1970-06-16
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414195
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7555
- Coverage period
- 2021-11-01 to present
- Deductible
- $96.69 of $500.0019%
- Out-of-pocket maximum
- $552.51 of $2,000.0028%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 4714883939
- Location
- Minneapolis, MN · TIN 48-3708210
- 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 | $458.00 | $206.10 | — | — | DeniedCO29 |
| Totals | $458.00 | $206.10 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-578252
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000572 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-22: CHOICE-PLUS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Fail | CO29 | Received 102 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Canyon Counseling Center2025-09-22 16:32
Patient seen for major depressive disorder, single episode, moderate.
- SystemSystem: Claims system2026-01-02 06:06
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 102 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.