CLM-2026-032815
Lakeside Behavioral Health, Behavioral Health. Service 2026-05-09 at office (POS 11). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Philip Vasquez
- Member ID
- UHC-19675-29
- Date of birth
- 1942-01-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422647
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9585
- Coverage period
- 2024-02-01 to present
- Deductible
- $705.93 of $1,500.0047%
- Out-of-pocket maximum
- $1,035.73 of $3,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 4082318484
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- none / REF477544
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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $184.00 | $82.80 | — | — | DeniedCO204 |
| 2 | 90791 | Psychiatric diagnostic evaluation | 25 | 1 | 2 | $415.00 | $186.75 | — | — | DeniedCO204 |
| Totals | $599.00 | $269.55 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- Patient account
- PA-363398
- 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-029010 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-09: NAVIGATE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 20 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 | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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 Health2026-05-09 15:45
Follow-up for post-traumatic stress disorder, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-29 01:27
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-29 16:58
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 2763853613 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034363 | 2026-10-06 | Cornerstone Digestive Health Center | $321.00 | Needs review |
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
No out-of-network benefit on this plan.