Claims workbench/CLM-2026-005708
Professional claim · CMS-1500 · EDI 837P

CLM-2026-005708

Meadow Physical Therapy, Physical Therapy. Service 2026-04-06 at office (POS 11). Received 2026-04-12.

Approved
Billed
$320.00
1 line
Allowed
$198.40
contract rate applied
Plan pays
$173.40
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
Justin Cruz
Member ID
UHC-59406-30
Date of birth
1944-09-18
Identity
Verified5 records, confidence 0.99
Claim record
CLMCLM-432427
Relationship
Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group -
Coverage period
2024-06-01 to present
Deductible
$475.07 of $3,500.0014%
Out-of-pocket maximum
$4,416.73 of $14,000.0032%
Copays
office $25.00, specialist $75.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Meadow Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
7881128434
Network
In network
Rendering NPI
8260934699
Location
Houston, TX · TIN 60-4048186
Authorisation / referral
none / REF629490

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—41$320.00$198.40$25.00$173.40Paid
Totals$320.00$198.40$25.00$173.40
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
Claim header
Patient account
PA-829951
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

CheckResultCodeDetail
Member identityPassAttached to MBR-025368 (verified, link confidence 0.99).
EligibilityPassActive on 2026-04-06: CORE-HMO (HMO), effective 2024-06-01.
Timely filingPassReceived 6 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Physical Therapy (7881128434).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsNotePhysical therapy visits used 18 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Meadow Physical Therapy2026-04-06 14:37

    Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$320.00
Plan discount
$121.60
contracted rate
Plan paid
$173.40
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Benefit limits: Physical therapy visits used 18 of 20.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0073092026-08-30Evergreen Orthopedic Specialists$1,297.00Approved

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.

Review queueMember identity