CLM-2026-030245
Sunrise Behavioral Health, Behavioral Health. Service 2026-07-21 at office (POS 11). Received 2026-08-09.
Member
Resolved through the identity graph
- Member
- Melissa Mendez
- Member ID
- UHC-41965-57
- Date of birth
- 1974-11-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412232
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5283
- Coverage period
- 2025-07-01 to present
- Deductible
- $160.30 of $1,500.0011%
- Out-of-pocket maximum
- $1,128.04 of $6,000.0019%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 3643766488
- Location
- Denver, CO · TIN 34-6918677
- 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 | $183.00 | $113.46 | — | — | PendedIDQ |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1,2 | $415.00 | $257.30 | — | — | PendedIDQ |
| Totals | $598.00 | $370.76 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-297117
- 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 | Fail | IDQ | Member record is in open steward case CASE-002452; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-07-21: MEDICARE-ADV-A (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 19 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2026-07-21 11:29
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002452; payment withheld until the identity is confirmed.
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
Clean claim, priced at contract rate.