CLM-2026-033905
Sunrise Counseling Center, Behavioral Health. Service 2026-06-03 at office (POS 11). Received 2026-07-27.
Member
Resolved through the identity graph
- Member
- Evelyn Nguyen
- Member ID
- UHC-91671-60
- Date of birth
- 1967-08-18
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-400487
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4783
- Coverage period
- 2023-12-01 to present
- Deductible
- $365.78 of $1,500.0024%
- Out-of-pocket maximum
- $2,831.22 of $6,000.0047%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 6738075996
- Network
- In network
- Rendering NPI
- 5083735113
- Location
- Miami, FL · TIN 80-4501911
- Authorisation / referral
- none / REF966401
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 | $366.00 | $226.92 | — | — | Review |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 2 | $216.00 | $133.92 | — | — | Review |
| Totals | $582.00 | $360.84 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-877875
- 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-019061 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-03: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 54 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-033904, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Counseling Center (6738075996). | |
| 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 Counseling Center2026-06-03 10:42
Established patient presents with major depressive disorder, single episode, moderate; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-27 02:13
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-033904, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033904 | 2026-06-03 | Pinecrest Behavioral Health | $582.00 | Approved |
| CLM-2026-008173 | 2026-03-20 | Canyon Heart Institute | $617.00 | Denied |
| CLM-2026-021261 | 2026-02-01 | Sunrise Internal Medicine Associates | $270.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.