CLM-2026-029716
Evergreen Counseling Center, Behavioral Health. Service 2026-05-15 at telehealth (POS 02). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Stephen Padilla
- Member ID
- UHC-99631-53
- Date of birth
- 1952-08-02
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-430874
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1359
- Coverage period
- 2024-08-01 to present
- Deductible
- $1,060.29 of $2,500.0042%
- Out-of-pocket maximum
- $4,669.79 of $10,000.0047%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 1655463630
- Location
- Los Angeles, CA · TIN 43-3815206
- Authorisation / referral
- none / REF529691
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 | 99214 | Office visit, established patient, moderate complexity | 59 | 1 | 1 | $251.00 | $155.62 | — | — | Review |
| 2 | 90834 | Psychotherapy, 45 minutes | 59 | 1 | 1 | $216.00 | $133.92 | — | — | Review |
| Totals | $467.00 | $289.54 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- Patient account
- PA-944788
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032454 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-15: CORE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Pass | Received 12 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 Evergreen Counseling Center (9886050688). | |
| 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: Evergreen Counseling Center2026-05-15 10:03
Patient seen for generalized anxiety disorder. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-05-27 05:52
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-27 10:51
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Medical recordrecords_PA-944788.pdf22 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 engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.