Professional claim · CMS-1500 · EDI 837P
CLM-2026-024291
Sunrise Behavioral Health, Behavioral Health. Service 2026-01-20 at office (POS 11). Received 2026-02-14.
Approved
Billed
$439.00
2 lines
Allowed
$272.18
contract rate applied
Plan pays
$212.18
approved
Member owes
$60.00
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
- Christina Willis
- Member ID
- UHC-77345-52
- Date of birth
- 1977-01-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-422267
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7653
- Coverage period
- 2023-04-01 to 2026-02-16
- Deductible
- $2,124.02 of $2,500.0085%
- Out-of-pocket maximum
- $1,016.46 of $5,000.0020%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 1271294492
- Location
- Denver, CO · TIN 34-6918677
- Authorisation / referral
- none / REF908996
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 | — | 1 | 1 | $140.00 | $86.80 | $60.00 | $26.80 | Paid |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1,2 | $299.00 | $185.38 | $0.00 | $185.38 | Paid |
| Totals | $439.00 | $272.18 | $60.00 | $212.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
Claim header
- Patient account
- PA-497303
- 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-012962 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-20: CORE-HMO (HMO), effective 2023-04-01, terms 2026-02-16. | |
| Timely filing | Pass | Received 25 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 (2247079397). | |
| 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: Sunrise Behavioral Health2026-01-20 09:53
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$439.00
Plan discount
$166.82
contracted rate
Plan paid
$212.18
You may owe
$60.00
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-2026-033986 | 2026-03-03 | Evergreen Medical Group | $195.00 | Denied |
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.