Claims workbench/CLM-2026-029594
Professional claim · CMS-1500 · EDI 837P

CLM-2026-029594

Heritage Behavioral Health, Behavioral Health. Service 2026-04-22 at office (POS 11). Received 2026-05-01.

Approved
Billed
$244.00
1 line
Allowed
$151.28
contract rate applied
Plan pays
$76.28
approved
Member owes
$75.00
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
Susan Wheeler
Member ID
UHC-05761-35
Date of birth
1947-05-28
Identity
Verified2 records, confidence 0.96
Claim record
CLMCLM-430534
Relationship
Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-6365
Coverage period
2025-10-01 to present
Deductible
$3.35 of $500.001%
Out-of-pocket maximum
$468.68 of $1,000.0047%
Copays
office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits
15 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI
3499047843
Network
In network
Rendering NPI
6397862544
Location
Minneapolis, MN · TIN 71-8171673
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190837Psychotherapy, 60 minutes—11$244.00$151.28$75.00$76.28Paid
Totals$244.00$151.28$75.00$76.28
Diagnoses (ICD-10-CM)
  • 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
  • 2. F90.2 ADHD, combined type
Claim header
Patient account
PA-802975
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-028685 (verified, link confidence 0.96).
EligibilityPassActive on 2026-04-22: NULL (PPO), effective 2025-10-01.
Timely filingPassReceived 9 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Behavioral Health (3499047843).
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: Heritage Behavioral Health2026-04-22 17:14

    Established patient presents with post-traumatic stress disorder, unspecified; 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
$244.00
Plan discount
$92.72
contracted rate
Plan paid
$76.28
You may owe
$75.00
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