CLM-2026-032530
Evergreen Counseling Center, Behavioral Health. Service 2026-04-30 at telehealth (POS 02). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Pamela Jackson
- Member ID
- UHC-56346-66
- Date of birth
- 1959-03-14
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-408112
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8293
- Coverage period
- 2024-08-01 to present
- Deductible
- $482.80 of $1,000.0048%
- Out-of-pocket maximum
- $126.74 of $3,000.004%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 9886050688
- Network
- In network
- Rendering NPI
- 7281863374
- Location
- Los Angeles, CA · TIN 43-3815206
- Authorisation / referral
- none / REF651528
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 | $239.00 | $148.18 | $75.00 | $73.18 | Paid |
| Totals | $239.00 | $148.18 | $75.00 | $73.18 | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-764658
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-033990 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-30: CORE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Pass | Received 38 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 Evergreen Counseling Center (9886050688). | |
| 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: Evergreen Counseling Center2026-04-30 14:11
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 12:44Clean claim.
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.