CLM-2026-029947
Pinecrest Behavioral Health, Behavioral Health. Service 2026-08-15 at office (POS 11). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Alan Gomez
- Member ID
- UHC-96329-04
- Date of birth
- 1970-09-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-402284
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8928
- Coverage period
- 2021-02-01 to present
- Deductible
- $744.45 of $1,000.0074%
- Out-of-pocket maximum
- $1,077.95 of $4,000.0027%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 1563891310
- Location
- Nashville, TN · TIN 20-1333588
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $294.00 | $182.28 | — | — | DeniedCO18 |
| 2 | 90791 | Psychiatric diagnostic evaluation | 25 | 1 | 1 | $406.00 | $251.72 | — | — | DeniedCO18 |
| Totals | $700.00 | $434.00 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-766853
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002828 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-15: N/A (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 62 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-029946: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Behavioral Health (2968932766). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Behavioral Health2026-08-15 18:41
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-16 06:03
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-16 11:13
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-029946: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029946 | 2026-08-15 | Pinecrest Behavioral Health | $700.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.