CLM-2026-034605
Sunrise Behavioral Health, Behavioral Health. Service 2026-05-20 at telehealth (POS 02). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Omar Contreras
- Member ID
- UHC-81935-53
- Date of birth
- 1990-04-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409180
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8944
- Coverage period
- 2021-07-01 to present
- Deductible
- $479.73 of $1,000.0048%
- Out-of-pocket maximum
- $827.16 of $4,000.0021%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 9180644400
- Network
- In network
- Rendering NPI
- 6511685268
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $221.00 | $137.02 | — | — | DeniedCO29 |
| Totals | $221.00 | $137.02 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-545765
- 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-027631 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-20: SELECT-EPO (EPO), effective 2021-07-01. | |
| Timely filing | Fail | CO29 | Received 109 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 Health2026-05-20 13:38
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-06 00:36
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 109 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029579 | 2026-05-13 | Valley Clinical Laboratories | $91.00 | Denied |
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.