Professional claim · CMS-1500 · EDI 837P
CLM-2026-007079
Unity Physical Therapy, Physical Therapy. Service 2026-06-11 at office (POS 11). Received 2026-07-01.
Billed
$328.00
1 line
Allowed
$203.36
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Eric Castillo
- Member ID
- UHC-84548-13
- Date of birth
- 1941-01-03
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-421113
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7501
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,465.65 of $3,500.0042%
- Out-of-pocket maximum
- $4,705.28 of $10,500.0045%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8723835475
- Network
- In network
- Rendering NPI
- 6978876590
- Location
- Houston, TX · TIN 17-6644986
- 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 | $328.00 | $203.36 | — | — | PendedIDQ |
| Totals | $328.00 | $203.36 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-854995
- 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 | Fail | IDQ | Member record is in open steward case CASE-004118; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-11: MEDICARE-ADV-A (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 20 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 Unity Physical Therapy (8723835475). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 0 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. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Physical Therapy2026-06-11 16:12
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-004118; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007080 | 2026-06-11 | Unity Physical Therapy | $328.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.