CLM-2026-027764
Pinecrest Behavioral Health, Behavioral Health. Service 2026-01-21 at office (POS 11). Received 2026-02-13.
Member
Resolved through the identity graph
- Member
- Omar Valdez
- Member ID
- UHC-08703-94
- Date of birth
- 1961-04-21
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-425612
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0347
- Coverage period
- 2021-05-01 to present
- Deductible
- $2,061.37 of $3,500.0059%
- Out-of-pocket maximum
- $2,661.46 of $7,000.0038%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 6354399464
- Location
- Nashville, TN · TIN 20-1333588
- Authorisation / referral
- none / REF306104
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 | $192.00 | $119.04 | $60.00 | $59.04 | Paid |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 2 | $203.00 | $125.86 | $0.00 | $125.86 | Paid |
| Totals | $395.00 | $244.90 | $60.00 | $184.90 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-576839
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003951 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-21: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 23 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 Pinecrest Behavioral Health (2968932766). | |
| 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: Pinecrest Behavioral Health2026-01-21 13:31
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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
Clean claim, priced at contract rate.