CLM-2026-027894
Lakeside Behavioral Health, Behavioral Health. Service 2025-12-11 at office (POS 11). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Joseph Richardson
- Member ID
- UHC-87640-10
- Date of birth
- 1962-04-11
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-400112
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4904
- Coverage period
- 2025-07-01 to present
- Deductible
- $1,942.91 of $2,500.0078%
- Out-of-pocket maximum
- $4,581.87 of $10,000.0046%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 9851204963
- Location
- Austin, TX · TIN 90-0644488
- 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 | 90834 | Psychotherapy, 45 minutes | 59 | 1 | 1 | $172.00 | $77.40 | — | — | Review |
| 2 | 90837 | Psychotherapy, 60 minutes | 59 | 1 | 2 | $203.00 | $91.35 | — | — | Review |
| Totals | $375.00 | $168.75 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-220951
- 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-002199 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2025-12-11: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 27 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Lakeside Behavioral Health2025-12-11 13:30
Established patient presents with adhd, combined type; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-07 00:59
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-220951.pdf10 pages
Operative note describes a single procedure at one site; no separate session.
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. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:15The claim includes two psychotherapy services (90834 and 90837) billed with modifier 59, which is used to indicate a distinct procedural service. However, the clinical note [N1] states that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, as the services are not distinct. According to NCCI rules, these services are normally bundled, and the use of modifier 59 is not supported by the documentation. Therefore, the claim is denied with reason code CO97 (Benefit included in another service already adjudicated).
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 8fa58fbf
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016285 | 2026-07-23 | Lakeside Internal Medicine Associates | $358.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes two psychotherapy services (90834 and 90837) billed with modifier 59, which is used to indicate a distinct procedural service. However, the clinical note [N1] states that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, as the services are not distinct. According to NCCI rules, these services are normally bundled, and the use of modifier 59 is not supported by the documentation. Therefore, the claim is denied with reason code CO97 (Benefit included in another service already adjudicated).
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.