Claims workbench/CLM-2026-009156
Professional claim · CMS-1500 · Provider portal

CLM-2026-009156

Evergreen Rehabilitation Center, Physical Therapy. Service 2026-09-18 at office (POS 11). Received 2026-09-22.

Approved
Billed
$178.00
1 line
Allowed
$110.36
contract rate applied
Plan pays
$90.36
approved
Member owes
$20.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Heather Fuller
Member ID
UHC-24859-05
Date of birth
1938-10-26
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-403943
Relationship
Self, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-4700
Coverage period
2025-09-01 to present
Deductible
$129.24 of $3,500.004%
Out-of-pocket maximum
$899.05 of $7,000.0013%
Copays
office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits
17 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
8258289502
Network
In network
Rendering NPI
7017637944
Location
Phoenix, AZ · TIN 14-6171767
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—21$178.00$110.36$20.00$90.36Paid
Totals$178.00$110.36$20.00$90.36
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-716818
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-027653 (verified, link confidence 0.99).
EligibilityPassActive on 2026-09-18: MEDICARE-ADV-B (MA), effective 2025-09-01.
Timely filingPassReceived 4 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Rehabilitation Center (8258289502).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 17 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: Evergreen Rehabilitation Center2026-09-18 10:44

    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
$178.00
Plan discount
$67.64
contracted rate
Plan paid
$90.36
You may owe
$20.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

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.

Review queueMember identity