Professional claim · CMS-1500 · EDI 837P
CLM-2026-030164
Canyon Counseling Center, Behavioral Health. Service 2026-05-27 at office (POS 11). Received 2026-06-02.
ApprovedOut of network
Billed
$562.00
2 lines
Allowed
$252.90
contract rate applied
Plan pays
$202.90
approved
Member owes
$50.00
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
- Judith Simmons
- Member ID
- UHC-35607-99
- Date of birth
- 1980-07-16
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-422616
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1460
- Coverage period
- 2021-12-01 to present
- Deductible
- $49.72 of $500.0010%
- Out-of-pocket maximum
- $298.53 of $2,000.0015%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 1279449718
- Network
- Out of network
- Rendering NPI
- 4802933372
- Location
- Minneapolis, MN · TIN 48-3708210
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $318.00 | $143.10 | $50.00 | $93.10 | Paid |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1,2 | $244.00 | $109.80 | $0.00 | $109.80 | Paid |
| Totals | $562.00 | $252.90 | $50.00 | $202.90 | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F90.2 ADHD, combined type
Claim header
- Patient account
- PA-517471
- 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-033296 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-27: OPTIONS-PPO (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 6 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Canyon Counseling Center2026-05-27 09:29
Patient seen for generalized anxiety disorder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$562.00
Plan discount
$309.10
out-of-network allowance
Plan paid
$202.90
You may owe
$50.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029400 | 2026-06-07 | Canyon Reference Lab | $173.00 | 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.