CLM-2026-032558
Northgate Counseling Center, Behavioral Health. Service 2026-04-30 at telehealth (POS 02). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Donna Ramirez
- Member ID
- UHC-71663-58
- Date of birth
- 1978-07-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-425984
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8207
- Coverage period
- 2021-02-01 to 2026-02-02
- Deductible
- $3,091.76 of $3,500.0088%
- Out-of-pocket maximum
- $684.46 of $14,000.005%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4860306727
- Network
- In network
- Rendering NPI
- 6486887675
- Location
- Austin, TX · TIN 78-2836028
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $227.00 | $140.74 | — | — | DeniedCO27 |
| Totals | $227.00 | $140.74 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-140165
- 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-019220 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-30 is after coverage terminated on 2026-02-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 Northgate Counseling Center (4860306727). | |
| 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: Northgate Counseling Center2026-04-30 15:19
Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-03 04:21
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-30 is after coverage terminated on 2026-02-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020040 | 2026-01-30 | Unity Bone and Joint Center | $12,102.00 | 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
Service after coverage termination.