CLM-2026-031864
Heritage Behavioral Health, Behavioral Health. Service 2026-03-01 at office (POS 11). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Mark Washington
- Member ID
- UHC-53180-18
- Date of birth
- 2006-12-27
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-421650
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7600
- Coverage period
- 2024-03-01 to present
- Deductible
- $544.89 of $1,500.0036%
- Out-of-pocket maximum
- $2,451.55 of $6,000.0041%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 2105372553
- Location
- Minneapolis, MN · TIN 71-8171673
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $180.00 | $111.60 | $50.00 | $61.60 | Paid |
| Totals | $180.00 | $111.60 | $50.00 | $61.60 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-911442
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004115 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-01: SELECT-EPO (EPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 32 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 Heritage Behavioral Health (3499047843). | |
| 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: Heritage Behavioral Health2026-03-01 14:24
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008538 | 2026-09-22 | Heritage Rehabilitation Center | $242.00 | Approved |
| CLM-2026-004448 | 2025-12-24 | Harbor Rehabilitation Center | $275.00 | Denied |
| CLM-2026-004447 | 2025-12-24 | Harbor Rehabilitation Center | $275.00 | Approved |
| CLM-2026-018099 | 2025-12-08 | Lakeside Physical Therapy | $207.00 | Approved |
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.