Claims workbench/CLM-2026-014421
Professional claim · CMS-1500 · EDI 837P

CLM-2026-014421

Harbor Rehabilitation Center, Physical Therapy. Service 2026-10-04 at office (POS 11). Received 2026-10-16.

Approved
Billed
$224.00
1 line
Allowed
$138.88
contract rate applied
Plan pays
$108.88
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
Rachel Bradley
Member ID
UHC-97573-46
Date of birth
1943-10-26
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-407941
Relationship
Self, Dallas, TX

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-1157
Coverage period
2022-01-01 to present
Deductible
$1,307.34 of $1,500.0087%
Out-of-pocket maximum
$26.42 of $6,000.000%
Copays
office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits
15 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
5301440876
Network
In network
Rendering NPI
2942454556
Location
Denver, CO · TIN 55-4519384
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—41$224.00$138.88$30.00$108.88Paid
Totals$224.00$138.88$30.00$108.88
Diagnoses (ICD-10-CM)
  • 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
  • 2. M25.561 Pain in right knee
Claim header
Patient account
PA-817607
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-032751 (verified, link confidence 0.99).
EligibilityPassActive on 2026-10-04: SELECT-EPO (EPO), effective 2022-01-01.
Timely filingPassReceived 12 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Rehabilitation Center (5301440876).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 15 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: Harbor Rehabilitation Center2026-10-04 10:03

    Established patient presents with unspecified rotator cuff tear, unspecified shoulder; 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
$224.00
Plan discount
$85.12
contracted rate
Plan paid
$108.88
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