Professional claim · CMS-1500 · EDI 837P
CLM-2026-012049
Meadow Physical Therapy, Physical Therapy. Service 2026-05-08 at office (POS 11). Received 2026-06-11.
ApprovedOut of network
Billed
$354.00
2 lines
Allowed
$159.30
contract rate applied
Plan pays
$134.30
approved
Member owes
$25.00
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
- Ahmed Vega
- Member ID
- UHC-03347-26
- Date of birth
- 1953-09-25
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-426946
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8683
- Coverage period
- 2023-05-01 to present
- Deductible
- $158.70 of $1,500.0011%
- Out-of-pocket maximum
- $374.72 of $4,500.008%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 7691599485
- Location
- Denver, CO · TIN 57-2119772
- 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 | $296.00 | $133.20 | $25.00 | $108.20 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $58.00 | $26.10 | $0.00 | $26.10 | Paid |
| Totals | $354.00 | $159.30 | $25.00 | $134.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
Claim header
- Patient account
- PA-695887
- 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-026655 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-08: OPTIONS-PPO (PPO), effective 2023-05-01. | |
| Timely filing | Pass | Received 34 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 3 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: Meadow Physical Therapy2026-05-08 11:01
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
$354.00
Plan discount
$194.70
out-of-network allowance
Plan paid
$134.30
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007191 | 2026-08-31 | Mesa Reference Lab | $89.00 | Denied |
| CLM-2026-007190 | 2026-08-31 | Mesa Reference Lab | $89.00 | Approved |
| CLM-2026-011933 | 2026-05-19 | Harbor Medical Group | $216.00 | 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.