Member
9141
Billing provider
11537
DOS
2025-11-02
DB status
paid
Total charge
$79.70
Allowed
$44.21
Paid
$39.65
Member resp.
$4.56
Claim lines (1)
| # | Procedure | Mod | Units | Charge | Allowed | Paid |
|---|---|---|---|---|---|---|
| 1 | S90834 | 1 | $79.70 | $44.21 | $39.65 |
Diagnoses: F32.9*E66.9M19.90
Agent chain trace
intake_validator6 tool call(s)provider_lookupprovider 11537: NPI 1851831028 (organization, 207Q00000X) active136mseligibility_lookupmember 9141: enrolled in plan 29 (self_spouse) on 2025-11-02166mscode_lookupCPT S90834: Synthetic Psychotherapy 45 Minutes (active)173mscode_lookupICD-10-CM F32.9: Major depressive disorder single episode unspecified (active)135mscode_lookupICD-10-CM E66.9: Obesity unspecified (active)193mscode_lookupICD-10-CM M19.90: Unspecified osteoarthritis unspecified site (active)208ms
eligibility1 tool call(s)eligibility_lookupmember 9141: enrolled in plan 29 (self_spouse) on 2025-11-02237ms
coding_edits2 tool call(s)mue_checkno MUE rule for S90834 on 2025-11-02161msncci_checkno NCCI PTP rule for S90834+S90834 on 2025-11-02129ms
pricing1 tool call(s)fee_schedule_lookupno fee schedule line for S90834 on 2025-11-02150ms
Review gate decisions (1)
pend_to_humanpayby
disposition · conf 0.602026-04-26 01:49:17confidence_below_thresholddollar_within_caprules_verified_by_agent_tool_callsno_risk_flags
Explanation of Benefits
Status: paidClaim
264347
Member
9141
Provider
11537
Date(s) of Service
2025-11-02
| Service | Charged | Allowed | Not covered | Plan paid | You owe |
|---|---|---|---|---|---|
| S90834 | $79.70 | $44.21 | $35.49 | $39.65 | $4.56 |
| Totals | $79.70 | $44.21 | $35.49 | $39.65 | $4.56 |
This EOB reflects amounts on the claim record. For chain-proposed figures (which may differ when the chain used synthetic-rate fallback), see the agent trace above — pricing/v0.2.0 emits a
synthetic_rate_used risk_flag when fee schedule data was missing.pend_to_human on 2026-04-26 01:49:17 per policy 1.