Professional claim · CMS-1500 · EDI 837P
CLM-2026-006263
Desert Rehabilitation Center, Physical Therapy. Service 2026-07-24 at office (POS 11). Received 2026-08-22.
Approved
Billed
$452.00
3 lines
Allowed
$280.24
contract rate applied
Plan pays
$260.24
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Arjun Gardner
- Member ID
- UHC-24635-15
- Date of birth
- 1987-08-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-401373
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0348
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,884.37 of $2,500.0075%
- Out-of-pocket maximum
- $2,854.37 of $7,500.0038%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1142322233
- Network
- In network
- Rendering NPI
- 7330782971
- Location
- Mesa, AZ · TIN 33-5650925
- 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 | — | 4 | 1 | $348.00 | $215.76 | $20.00 | $195.76 | Paid |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $34.00 | $21.08 | $0.00 | $21.08 | Paid |
| 3 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 2 | $70.00 | $43.40 | $0.00 | $43.40 | Paid |
| Totals | $452.00 | $280.24 | $20.00 | $260.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-247847
- 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-023124 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-24: SELECT-EPO (EPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 29 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 Desert Rehabilitation Center (1142322233). | |
| 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 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Rehabilitation Center2026-07-24 11:06
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$452.00
Plan discount
$171.76
contracted rate
Plan paid
$260.24
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028525 | 2026-03-27 | Heritage Behavioral Health | $539.00 | Approved |
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.