CLM-2026-032892
Sunrise Behavioral Health, Behavioral Health. Service 2026-04-20 at office (POS 11). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Jacob Turner
- Member ID
- UHC-72094-54
- Date of birth
- 1993-10-01
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-423857
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9158
- Coverage period
- 2024-03-01 to present
- Deductible
- $232.79 of $2,500.009%
- Out-of-pocket maximum
- $2,298.19 of $10,000.0023%
- Copays
- office $20.00, specialist $50.00, 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
- 6948274975
- Location
- Dallas, TX · TIN 81-8341944
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $228.00 | $141.36 | — | — | DeniedCO29 |
| 2 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $315.00 | $195.30 | — | — | DeniedCO29 |
| Totals | $543.00 | $336.66 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-588847
- 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-020804 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-20: UNKNOWN (PPO), effective 2024-03-01. | |
| Timely filing | Fail | CO29 | Received 147 days after the last date of service (limit 90). Time limit for filing has expired |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Behavioral Health2026-04-20 12:49
Patient seen for adhd, combined type.
- SystemSystem: Claims system2026-09-14 06:53
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 147 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013906 | 2026-03-05 | Sunrise Skin Care Associates | $965.00 | 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
Received after the timely-filing limit.