CLM-2026-031999
Lakeside Behavioral Health, Behavioral Health. Service 2026-09-16 at office (POS 11). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Dorothy Herrera
- Member ID
- UHC-12392-13
- Date of birth
- 1952-04-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405698
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1240
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,642.86 of $2,500.0066%
- Out-of-pocket maximum
- $3,361.38 of $10,000.0034%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- 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
- 7361867113
- 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 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $191.00 | $85.95 | — | — | DeniedCO18 |
| Totals | $191.00 | $85.95 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-940061
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024206 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-16: OPTIONS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031998: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Health2026-09-16 18:18
Patient seen for adhd, combined type.
- SystemSystem: Claims system2026-10-15 02:38
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-15 09:47
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-031998: same member, date of service, procedures and billing provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031998 | 2026-09-16 | Lakeside Behavioral Health | $191.00 | Approved |
| CLM-2026-015811 | 2026-08-09 | Sunrise Clinical Laboratories | $124.00 | Approved |
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.