Professional claim · CMS-1500 · EDI 837P
CLM-2026-011251
Sunrise Physical Therapy, Physical Therapy. Service 2026-01-12 at office (POS 11). Received 2026-02-18.
Approved
Billed
$445.00
3 lines
Allowed
$275.90
contract rate applied
Plan pays
$250.90
approved
Member owes
$25.00
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
- Justin Cooper
- Member ID
- UHC-19536-68
- Date of birth
- 1943-04-08
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-401953
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2805
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,393.80 of $2,500.0056%
- Out-of-pocket maximum
- $21.90 of $5,000.000%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 2469614764
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF715050
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 | — | 2 | 1 | $144.00 | $89.28 | $25.00 | $64.28 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $251.00 | $155.62 | $0.00 | $155.62 | Paid |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $50.00 | $31.00 | $0.00 | $31.00 | Paid |
| Totals | $445.00 | $275.90 | $25.00 | $250.90 | ||||||
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-900814
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014103 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-12: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 37 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 Sunrise Physical Therapy (7462471310). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 14 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within 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: Sunrise Physical Therapy2026-01-12 17:18
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
$445.00
Plan discount
$169.10
contracted rate
Plan paid
$250.90
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010327 | 2026-06-30 | Riverside Internal Medicine Associates | $85.00 | Approved |
| CLM-2026-025004 | 2026-02-13 | Northgate Medical Group | $203.00 | 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.