Professional claim · CMS-1500 · Provider portal
CLM-2026-002395
Pinecrest Physical Therapy, Physical Therapy. Service 2026-07-16 at office (POS 11). Received 2026-08-13.
Approved
Billed
$199.00
2 lines
Allowed
$123.38
contract rate applied
Plan pays
$98.38
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Pamela Bryant
- Member ID
- UHC-85849-44
- Date of birth
- 1960-03-17
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-418321
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-2604
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,640.13 of $2,500.0066%
- Out-of-pocket maximum
- $1,432.81 of $7,500.0019%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 7574234432
- Location
- Austin, TX · TIN 13-9684371
- 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 | 97110 | Therapeutic exercise, 15 minutes | — | 2 | 1 | $132.00 | $81.84 | $25.00 | $56.84 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $67.00 | $41.54 | $0.00 | $41.54 | Paid |
| Totals | $199.00 | $123.38 | $25.00 | $98.38 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-397997
- 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-039374 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-16: N/A (PPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Physical Therapy (8020189691). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 19 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Physical Therapy2026-07-16 12:27
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$199.00
Plan discount
$75.62
contracted rate
Plan paid
$98.38
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.