CLM-2026-031771
Lakeside Behavioral Health, Behavioral Health. Service 2026-03-30 at office (POS 11). Received 2026-05-04.
Member
Resolved through the identity graph
- Member
- Luis Tucker
- Member ID
- UHC-25918-17
- Date of birth
- 1953-09-13
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-422275
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6928
- Coverage period
- 2025-07-01 to present
- Deductible
- $1,271.27 of $1,500.0085%
- Out-of-pocket maximum
- $1,888.10 of $4,500.0042%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 3444402721
- Location
- Austin, TX · TIN 90-0644488
- 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 | $246.00 | $110.70 | $60.00 | $50.70 | Paid |
| Totals | $246.00 | $110.70 | $60.00 | $50.70 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-203659
- 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-010949 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-30: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 35 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Behavioral Health2026-03-30 12:55
Patient seen for post-traumatic stress disorder, unspecified.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.