CLM-2026-033522
Sunrise Behavioral Health, Behavioral Health. Service 2026-02-25 at office (POS 11). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Brenda Adams
- Member ID
- UHC-68921-36
- Date of birth
- 1953-06-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-420436
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4089
- Coverage period
- 2022-01-01 to present
- Deductible
- $537.10 of $1,000.0054%
- Out-of-pocket maximum
- $326.54 of $2,000.0016%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 6556850348
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $378.00 | $234.36 | — | — | DeniedCO18 |
| Totals | $378.00 | $234.36 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-956682
- 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-014397 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-25: MEDICARE-ADV-B (MA), effective 2022-01-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-033521: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Health2026-02-25 12:21
Patient seen for adhd, combined type.
- SystemSystem: Claims system2026-03-21 06:19
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-21 14:13
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 13:43Duplicate check: Exact duplicate of CLM-2026-033521: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000492 | 2026-05-08 | Summit Reference Lab | $193.00 | Approved |
| CLM-2026-033521 | 2026-02-25 | Sunrise Behavioral Health | $378.00 | 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
Exact duplicate of an earlier submission.