CLM-2026-031726
Northgate Counseling Center, Behavioral Health. Service 2026-06-21 at telehealth (POS 02). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Samantha Henderson
- Member ID
- UHC-28244-02
- Date of birth
- 1945-01-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416669
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6522
- Coverage period
- 2022-02-01 to present
- Deductible
- $570.73 of $1,000.0057%
- Out-of-pocket maximum
- $183.53 of $3,000.006%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4860306727
- Network
- In network
- Rendering NPI
- 9959298503
- Location
- Austin, TX · TIN 78-2836028
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $276.00 | $171.12 | — | — | DeniedCO18 |
| Totals | $276.00 | $171.12 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- Patient account
- PA-493587
- 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-022562 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-21: MEDICARE-ADV-B (MA), effective 2022-02-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031725: 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 Northgate Counseling Center (4860306727). | |
| 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: Northgate Counseling Center2026-06-21 10:11
Patient seen for major depressive disorder, single episode, moderate.
- SystemSystem: Claims system2026-07-06 02:01
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-06 09:25
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-031725: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031725 | 2026-06-21 | Northgate Counseling Center | $276.00 | Approved |
| CLM-2026-034522 | 2026-05-24 | Desert Diagnostic Imaging | $2,025.00 | Denied |
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.