Professional claim · CMS-1500 · EDI 837P
CLM-2026-011476
Evergreen Rehabilitation Center, Physical Therapy. Service 2026-01-20 at office (POS 11). Received 2026-01-23.
Approved
Billed
$426.00
3 lines
Allowed
$264.12
contract rate applied
Plan pays
$244.12
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Eugene Cruz
- Member ID
- UHC-78205-34
- Date of birth
- 1988-03-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-430276
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7110
- Coverage period
- 2022-07-01 to present
- Deductible
- $423.84 of $3,500.0012%
- Out-of-pocket maximum
- $312.05 of $7,000.004%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 1392066829
- Location
- Phoenix, AZ · TIN 14-6171767
- 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 | — | 2 | 1 | $112.00 | $69.44 | $20.00 | $49.44 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $231.00 | $143.22 | $0.00 | $143.22 | Paid |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $83.00 | $51.46 | $0.00 | $51.46 | Paid |
| Totals | $426.00 | $264.12 | $20.00 | $244.12 | ||||||
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-594344
- 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-007064 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-20: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 3 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 Evergreen Rehabilitation Center (8258289502). | |
| 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: Evergreen Rehabilitation Center2026-01-20 13:14
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
$426.00
Plan discount
$161.88
contracted rate
Plan paid
$244.12
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-2026-013171 | 2026-02-27 | Northgate Clinical Laboratories | $118.00 | Approved |
| CLM-2026-014846 | 2025-12-23 | Northgate Orthopedic Specialists | $439.00 | 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.