Claims workbench/CLM-2026-029221
Professional claim · CMS-1500 · EDI 837P

CLM-2026-029221

Sunrise Behavioral Health, Behavioral Health. Service 2026-06-28 at office (POS 11). Received 2026-07-30.

Approved
Billed
$328.00
2 lines
Allowed
$203.36
contract rate applied
Plan pays
$143.36
approved
Member owes
$60.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Alexis Singh
Member ID
UHC-47408-81
Date of birth
1985-11-15
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-431660
Relationship
Self, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-8982
Coverage period
2022-10-01 to present
Deductible
$1,317.41 of $1,500.0088%
Out-of-pocket maximum
$1,235.07 of $4,500.0027%
Copays
office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI
9180644400
Network
In network
Rendering NPI
2508849132
Location
Dallas, TX · TIN 81-8341944
Authorisation / referral
none / REF544852

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190837Psychotherapy, 60 minutes—11$187.00$115.94$60.00$55.94Paid
290834Psychotherapy, 45 minutes—12$141.00$87.42$0.00$87.42Paid
Totals$328.00$203.36$60.00$143.36
Diagnoses (ICD-10-CM)
  • 1. F32.1 Major depressive disorder, single episode, moderateprincipal
Claim header
Patient account
PA-154930
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

CheckResultCodeDetail
Member identityPassAttached to MBR-036718 (verified, link confidence 0.99).
EligibilityPassActive on 2026-06-28: NAVIGATE-HMO (HMO), effective 2022-10-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Behavioral Health (9180644400).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Behavioral Health2026-06-28 16:22

    Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$328.00
Plan discount
$124.64
contracted rate
Plan paid
$143.36
You may owe
$60.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity