Professional claim · CMS-1500 · EDI 837P
CLM-2026-013538
Sunrise Physical Therapy, Physical Therapy. Service 2026-02-15 at office (POS 11). Received 2026-02-20.
Approved
Billed
$244.00
1 line
Allowed
$151.28
contract rate applied
Plan pays
$131.28
approved
Member owes
$20.00
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
- Andrea Castillo
- Member ID
- UHC-62841-33
- Date of birth
- 1957-07-14
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-401495
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7493
- Coverage period
- 2022-04-01 to 2026-03-20
- Deductible
- $581.68 of $1,000.0058%
- Out-of-pocket maximum
- $1,073.39 of $3,000.0036%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 4869668226
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF630391
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 | $244.00 | $151.28 | $20.00 | $131.28 | Paid |
| Totals | $244.00 | $151.28 | $20.00 | $131.28 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-813412
- 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-001600 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-15: NAVIGATE-HMO (HMO), effective 2022-04-01, terms 2026-03-20. | |
| Timely filing | Pass | Received 5 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 2 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 Therapy2026-02-15 18:26
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$244.00
Plan discount
$92.72
contracted rate
Plan paid
$131.28
You may owe
$20.00
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
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.