Professional claim · CMS-1500 · EDI 837P
CLM-2026-032320
Sunrise Behavioral Health, Behavioral Health. Service 2026-10-07 at office (POS 11). Received 2026-10-12.
Denied
Billed
$547.00
2 lines
Allowed
$339.14
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Benjamin Contreras
- Member ID
- UHC-74433-78
- Date of birth
- 1980-06-23
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-414942
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9082
- Coverage period
- 2024-10-01 to 2026-05-05
- Deductible
- $309.32 of $1,500.0021%
- Out-of-pocket maximum
- $1,871.77 of $4,500.0042%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 5413117891
- Location
- Dallas, TX · TIN 81-8341944
- Authorisation / referral
- none / REF722847
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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $365.00 | $226.30 | — | — | DeniedCO27 |
| 2 | 90834 | Psychotherapy, 45 minutes | 25 | 1 | 1 | $182.00 | $112.84 | — | — | DeniedCO27 |
| Totals | $547.00 | $339.14 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. F41.1 Generalized anxiety disorderprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
Claim header
- Patient account
- PA-518249
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013639 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-07 is after coverage terminated on 2026-05-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Sunrise Behavioral Health (9180644400). | |
| 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. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2026-10-07 17:49
Patient seen for generalized anxiety disorder.
- SystemSystem: Claims system2026-10-12 01:24
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-07 is after coverage terminated on 2026-05-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028361 | 2026-06-14 | Valley Medical Group | $503.00 | Denied |
| CLM-2026-001038 | 2026-01-08 | Sunrise Imaging Center | $2,419.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.