CLM-2026-030005
Sunrise Behavioral Health, Behavioral Health. Service 2025-12-23 at office (POS 11). Received 2026-02-04.
Member
Resolved through the identity graph
- Member
- Diane Reid
- Member ID
- UHC-19446-14
- Date of birth
- 1954-02-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419801
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7325
- Coverage period
- 2022-12-01 to present
- Deductible
- $3,082.65 of $3,500.0088%
- Out-of-pocket maximum
- $3,317.97 of $7,000.0047%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3600193734
- Location
- Denver, CO · TIN 34-6918677
- Authorisation / referral
- none / REF191396
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 | $166.00 | $102.92 | — | — | Review |
| Totals | $166.00 | $102.92 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-235400
- 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-010405 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-23: CORE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 43 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 | Review | CO16 | Documentation incomplete: “Established patient presents with adhd, combined type; symptoms reviewed and vitals within”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2025-12-23 10:57
Established patient presents with adhd, combined type; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-04 05:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-04 09:19
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with adhd, combined type; symptoms reviewed and vitals within”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002828 | 2026-08-08 | Lakeside Physical Therapy | $304.00 | Approved |
| CLM-2026-031775 | 2026-06-18 | Harbor Family Practice | $213.00 | Approved |
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
Development letter outstanding.