Professional claim · CMS-1500 · Provider portal
CLM-2026-013140
Harbor Physical Therapy, Physical Therapy. Service 2026-04-14 at office (POS 11). Received 2026-04-24.
Approved
Billed
$289.00
3 lines
Allowed
$179.18
contract rate applied
Plan pays
$149.18
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
- Margaret Obrien
- Member ID
- UHC-43459-75
- Date of birth
- 1996-11-16
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-415349
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8513
- Coverage period
- 2025-03-01 to present
- Deductible
- $8.54 of $1,500.001%
- Out-of-pocket maximum
- $482.94 of $6,000.008%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 3698011350
- Location
- Miami, FL · TIN 59-6364489
- 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 | $154.00 | $95.48 | $30.00 | $65.48 | Paid |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 2 | $42.00 | $26.04 | $0.00 | $26.04 | Paid |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1,2 | $93.00 | $57.66 | $0.00 | $57.66 | Paid |
| Totals | $289.00 | $179.18 | $30.00 | $149.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-159037
- 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-027484 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-14: SELECT-EPO (EPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 10 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 Physical Therapy (9493518267). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 8 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 Physical Therapy2026-04-14 16:37
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
$289.00
Plan discount
$109.82
contracted rate
Plan paid
$149.18
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-2026-017113 | 2026-08-21 | Evergreen Medical Group | $488.00 | Approved |
| CLM-2026-001744 | 2026-05-10 | Canyon Primary Care Associates | $576.00 | Approved |
| CLM-2026-029515 | 2026-04-13 | Lakeside Physical Therapy | $273.00 | 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.