CLM-2026-027091
Sunrise Behavioral Health, Behavioral Health. Service 2026-09-13 at office (POS 11). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Arthur Hernandez
- Member ID
- UHC-81248-74
- Date of birth
- 2003-08-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406994
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5776
- Coverage period
- 2024-06-01 to present
- Deductible
- $228.40 of $3,500.007%
- Out-of-pocket maximum
- $2.99 of $10,500.000%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 3835281783
- Location
- Dallas, TX · TIN 81-8341944
- Authorisation / referral
- none / REF212743
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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $314.00 | $194.68 | $50.00 | $144.68 | Paid |
| Totals | $314.00 | $194.68 | $50.00 | $144.68 | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-837948
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025375 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-13: NAVIGATE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 32 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 Health2026-09-13 11:03
Follow-up for major depressive disorder, single episode, moderate. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-10-15 01:38
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-837948.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021968 | 2026-03-27 | Lakeside Regional Medical Center | $2,678.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.