CLM-2026-033158
Northgate Counseling Center, Behavioral Health. Service 2026-08-27 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- David Sullivan
- Member ID
- UHC-29415-94
- Date of birth
- 1983-02-03
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-414367
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5545
- Coverage period
- 2022-04-01 to 2026-07-06
- Deductible
- $367.88 of $1,000.0037%
- Out-of-pocket maximum
- $893.89 of $3,000.0030%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4860306727
- Network
- In network
- Rendering NPI
- 2465399881
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $295.00 | $182.90 | — | — | DeniedCO27 |
| 2 | 90837 | Psychotherapy, 60 minutes | — | 1 | 2 | $230.00 | $142.60 | — | — | DeniedCO27 |
| Totals | $525.00 | $325.50 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-778033
- 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-001156 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-27 is after coverage terminated on 2026-07-06. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 Center2026-08-27 18:52
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-17 03:56
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-17 09:00
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-27 is after coverage terminated on 2026-07-06.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012291 | 2026-06-08 | Lakeside Physical Therapy | $8,524.00 | 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
Service after coverage termination.