CLM-2026-024091
Sunrise Behavioral Health, Behavioral Health. Service 2026-07-13 at office (POS 11). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Isabella Robertson
- Member ID
- UHC-25638-63
- Date of birth
- 1988-01-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-427948
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2136
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,328.79 of $1,500.0089%
- Out-of-pocket maximum
- $1,331.36 of $4,500.0030%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 8807804959
- Location
- Dallas, TX · TIN 81-8341944
- 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 | 90834 | Psychotherapy, 45 minutes | 59 | 1 | 1 | $191.00 | $118.42 | — | — | Review |
| 2 | 90837 | Psychotherapy, 60 minutes | 59 | 1 | 2 | $242.00 | $150.04 | — | — | Review |
| Totals | $433.00 | $268.46 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- Patient account
- PA-187140
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023447 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-13: MEDICARE-ADV-A (MA), effective 2025-06-01. | |
| Timely filing | Pass | Received 6 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 Sunrise Behavioral Health (9180644400). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Sunrise Behavioral Health2026-07-13 15:45
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-07-19 06:40
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-187140.pdf18 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.