CLM-2026-025179
Sunrise Behavioral Health, Behavioral Health. Service 2026-07-11 at office (POS 11). Received 2026-07-24.
Member
Resolved through the identity graph
- Member
- Billy Bowman
- Member ID
- UHC-04524-02
- Date of birth
- 1957-02-15
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411940
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1466
- Coverage period
- 2022-04-01 to 2026-02-14
- Deductible
- $2,070.25 of $3,500.0059%
- Out-of-pocket maximum
- $4,465.27 of $10,500.0043%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 6810687536
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $242.00 | $150.04 | — | — | DeniedCO27 |
| Totals | $242.00 | $150.04 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- Patient account
- PA-561066
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-039479 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-11 is after coverage terminated on 2026-02-14. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 13 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) | 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: Sunrise Behavioral Health2026-07-11 12:54
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-24 06:09
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-11 is after coverage terminated on 2026-02-14.
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
Service after coverage termination.