CLM-2026-030937
Sunrise Behavioral Health, Behavioral Health. Service 2026-03-29 at telehealth (POS 02). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Elijah Taylor
- Member ID
- UHC-61760-09
- Date of birth
- 1985-04-15
- Identity
- Verified3 records, confidence 0.86
- Claim record
- CLMCLM-414019
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2206
- Coverage period
- 2025-07-01 to present
- Deductible
- $156.65 of $500.0031%
- Out-of-pocket maximum
- $987.04 of $2,000.0049%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2247079397
- Network
- In network
- Rendering NPI
- 5227028151
- Location
- Denver, CO · TIN 34-6918677
- Authorisation / referral
- none / REF449190
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 | — | 1 | 1 | $225.00 | $139.50 | — | — | DeniedCO29 |
| Totals | $225.00 | $139.50 | — | — | ||||||
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-435789
- 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-029455 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2026-03-29: NAVIGATE-HMO (HMO), effective 2025-07-01. | |
| Timely filing | Fail | CO29 | Received 144 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Health2026-03-29 09:09
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 05:04
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-20 13:38
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 144 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.