Professional claim · CMS-1500 · EDI 837P
CLM-2026-009278
Harbor Rehabilitation Center, Physical Therapy. Service 2026-03-18 at office (POS 11). Received 2026-04-19.
Approved
Billed
$517.00
3 lines
Allowed
$320.54
contract rate applied
Plan pays
$290.54
approved
Member owes
$30.00
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 Sullivan
- Member ID
- UHC-69356-13
- Date of birth
- 1967-11-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409401
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9442
- Coverage period
- 2025-07-01 to present
- Deductible
- $2,292.57 of $3,500.0066%
- Out-of-pocket maximum
- $1,282.88 of $7,000.0018%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 2688512807
- Location
- Mesa, AZ · TIN 48-8489623
- 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 | $224.00 | $138.88 | $30.00 | $108.88 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $246.00 | $152.52 | $0.00 | $152.52 | Paid |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $47.00 | $29.14 | $0.00 | $29.14 | Paid |
| Totals | $517.00 | $320.54 | $30.00 | $290.54 | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
Claim header
- Patient account
- PA-837212
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005474 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-18: SELECT-EPO (EPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 32 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 Harbor Rehabilitation Center (1139592160). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 16 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: Harbor Rehabilitation Center2026-03-18 17:35
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$517.00
Plan discount
$196.46
contracted rate
Plan paid
$290.54
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016646 | 2026-08-16 | Pinecrest Regional Medical Center | $2,470.00 | Needs review |
| CLM-2026-007467 | 2026-05-20 | Evergreen Medical Group | $296.00 | Approved |
| CLM-2026-018223 | 2026-02-12 | Unity Reference Lab | $119.00 | 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.