CLM-2026-025482
Canyon Counseling Center, Behavioral Health. Service 2026-10-08 at office (POS 11). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Ralph Harper
- Member ID
- UHC-54586-42
- Date of birth
- 2008-03-13
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-427962
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3520
- Coverage period
- 2021-10-01 to present
- Deductible
- $2,180.43 of $2,500.0087%
- Out-of-pocket maximum
- $641.95 of $7,500.009%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 2802838765
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $246.00 | $110.70 | — | — | Review |
| Totals | $246.00 | $110.70 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-109213
- 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-037384 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-08: MEDICARE-ADV-B (MA), effective 2021-10-01. | |
| Timely filing | Pass | Received 4 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 | 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 | Review | CO16 | Documentation incomplete: “Established patient presents with generalized anxiety disorder; symptoms reviewed and vita”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Counseling Center2026-10-08 15:06
Established patient presents with generalized anxiety disorder; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-12 00:23
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-12 13:44
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Established patient presents with generalized anxiety disorder; symptoms reviewed and vita”.
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
Development letter outstanding.