CLM-2026-034544
Northgate Counseling Center, Behavioral Health. Service 2025-09-22 at office (POS 11). Received 2026-04-24.
Member
Resolved through the identity graph
- Member
- Steven Medina
- Member ID
- UHC-03024-42
- Date of birth
- 1945-08-08
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-431260
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3266
- Coverage period
- 2023-06-01 to present
- Deductible
- $272.92 of $500.0055%
- Out-of-pocket maximum
- $96.88 of $1,000.0010%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4860306727
- Network
- In network
- Rendering NPI
- 6680704981
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $180.00 | $111.60 | — | — | DeniedCO29 |
| 2 | 90791 | Psychiatric diagnostic evaluation | 25 | 1 | 2 | $337.00 | $208.94 | — | — | DeniedCO29 |
| Totals | $517.00 | $320.54 | — | — | ||||||
- 1. F32.1 Major depressive disorder, single episode, moderateprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-179299
- 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-004979 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-09-22: CHOICE-PLUS-PPO (PPO), effective 2023-06-01. | |
| Timely filing | Fail | CO29 | Received 214 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 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 Center2025-09-22 16:25
Patient seen for major depressive disorder, single episode, moderate.
- SystemSystem: Claims system2026-04-24 00:25
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 214 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012508 | 2026-01-03 | Riverside Digestive Health Center | $264.00 | 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.