Professional claim · CMS-1500 · EDI 837P
CLM-2026-025077
Lakeside Behavioral Health, Behavioral Health. Service 2025-12-18 at office (POS 11). Received 2026-01-01.
ReceivedOut of network
Billed
$656.00
2 lines
Allowed
$0.00
if approved
Plan pays
—
Received
Member owes
—
no coverage
Rules engine
—
no reason codes
Decided by
Nobody yet
open
Member
Resolved through the identity graph
The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.
Coverage and accumulators
Eligibility
No coverage segment found for this member.
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 1270902327
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF160548
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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $283.00 | — | — | — | — |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $373.00 | — | — | — | — |
| Totals | $656.00 | $0.00 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F90.2 ADHD, combined type
Claim header
- Patient account
- PA-280625
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 0 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| The rules engine has not evaluated this claim. Run the pipeline. | |||
Notes
Provider, system and examiner notes on this claim
No notes.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
No history yet.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Outcome
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ExaminerR. Patel (Claims Examiner II)
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