CLM-2026-027093
Canyon Counseling Center, Behavioral Health. Service 2026-09-04 at telehealth (POS 02). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Billy Welch
- Member ID
- UHC-99018-57
- Date of birth
- 1988-04-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421493
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4687
- Coverage period
- 2024-07-01 to present
- Deductible
- $163.84 of $500.0033%
- Out-of-pocket maximum
- $579.25 of $1,500.0039%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 6159723785
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $288.00 | $129.60 | — | — | DeniedCO18 |
| Totals | $288.00 | $129.60 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-202364
- 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-041388 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-04: MEDICARE-ADV-A (MA), effective 2024-07-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-027092: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon Counseling Center2026-09-04 13:10
Follow-up for post-traumatic stress disorder, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-26 02:16
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-027092: same member, date of service, procedures and billing provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027092 | 2026-09-04 | Canyon Counseling Center | $288.00 | Approved |
| CLM-2026-006754 | 2026-07-22 | Pinecrest Cardiovascular Associates | $8,007.00 | Approved |
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
Exact duplicate of an earlier submission.