Professional claim · CMS-1500 · EDI 837P
CLM-2026-029524
Sunrise Behavioral Health, Behavioral Health. Service 2026-08-23 at office (POS 11). Received 2026-09-13.
Approved
Billed
$173.00
1 line
Allowed
$107.26
contract rate applied
Plan pays
$67.26
approved
Member owes
$40.00
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
- Emma Silva
- Member ID
- UHC-22819-36
- Date of birth
- 1977-06-11
- Identity
- Verified7 records, confidence 0.98
- Claim record
- CLMCLM-422440
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8265
- Coverage period
- 2023-02-01 to present
- Deductible
- $2,737.20 of $3,500.0078%
- Out-of-pocket maximum
- $3,211.53 of $7,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 1305193132
- Location
- Denver, CO · TIN 34-6918677
- 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 | — | 1 | 1 | $173.00 | $107.26 | $40.00 | $67.26 | Paid |
| Totals | $173.00 | $107.26 | $40.00 | $67.26 | ||||||
Diagnoses (ICD-10-CM)
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
Claim header
- Patient account
- PA-548574
- 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-000644 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-08-23: UNKNOWN (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 21 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 (2247079397). | |
| 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. |
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 Health2026-08-23 09:51
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$173.00
Plan discount
$65.74
contracted rate
Plan paid
$67.26
You may owe
$40.00
copay, deductible and coinsurance
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-2026-005034 | 2026-08-16 | Lakeside Internal Medicine Associates | $288.00 | Approved |
| CLM-2026-003575 | 2026-07-11 | Cornerstone Imaging Center | $1,624.00 | Needs review |
| CLM-2026-003574 | 2026-07-11 | Cornerstone Imaging Center | $1,624.00 | Needs review |
| CLM-2026-007225 | 2025-12-28 | Desert Reference Lab | $139.00 | Approved |
| CLM-2026-007230 | 2025-11-30 | Meadow Clinical Laboratories | $125.00 | Approved |
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.