Claims workbench/CLM-2026-013210
Professional claim · CMS-1500 · EDI 837P

CLM-2026-013210

Mesa Physical Therapy, Physical Therapy. Service 2026-05-05 at office (POS 11). Received 2026-05-22.

Approved
Billed
$136.00
1 line
Allowed
$84.32
contract rate applied
Plan pays
$54.32
approved
Member owes
$30.00
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
Linda Burns
Member ID
UHC-33371-57
Date of birth
1949-04-04
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-411538
Relationship
Spouse, Glendale, AZ

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-A MA group GRP-4985
Coverage period
2024-01-01 to 2026-06-24
Deductible
$722.77 of $1,000.0072%
Out-of-pocket maximum
$994.05 of $2,000.0050%
Copays
office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits
4 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
7870543981
Network
In network
Rendering NPI
6823672434
Location
Houston, TX · TIN 58-9513034
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—21$136.00$84.32$30.00$54.32Paid
Totals$136.00$84.32$30.00$54.32
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
  • 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
Patient account
PA-604361
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

CheckResultCodeDetail
Member identityPassAttached to MBR-031869 (verified, link confidence 0.97).
EligibilityPassActive on 2026-05-05: MEDICARE-ADV-A (MA), effective 2024-01-01, terms 2026-06-24.
Timely filingPassReceived 17 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Physical Therapy (7870543981).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 4 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Mesa Physical Therapy2026-05-05 16:23

    Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$136.00
Plan discount
$51.68
contracted rate
Plan paid
$54.32
You may owe
$30.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

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.

Review queueMember identity