CLM-2026-025778
Mesa Behavioral Health, Behavioral Health. Service 2026-07-18 at office (POS 11). Received 2026-08-01.
Member
Resolved through the identity graph
- Member
- Ruth Rice
- Member ID
- UHC-43044-60
- Date of birth
- 1958-04-09
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430402
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4802
- Coverage period
- 2023-11-01 to 2026-06-04
- Deductible
- $1,898.66 of $2,500.0076%
- Out-of-pocket maximum
- $681.15 of $10,000.007%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 3838909638
- Location
- Nashville, TN · TIN 40-4103519
- 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 | $256.00 | $158.72 | — | — | DeniedCO27 |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $339.00 | $210.18 | — | — | DeniedCO27 |
| Totals | $595.00 | $368.90 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-229498
- 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 | Fail | IDQ | Member record is in open steward case CASE-000503; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | CO27 | Date of service 2026-07-18 is after coverage terminated on 2026-06-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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 Mesa Behavioral Health (7796147859). | |
| 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: Mesa Behavioral Health2026-07-18 18:15
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-01 01:52
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-01 10:34
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 engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-000503; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-07-18 is after coverage terminated on 2026-06-04.
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.