Claims workbench/CLM-2026-016409
Professional claim · CMS-1500 · EDI 837P

CLM-2026-016409

Heritage Physical Therapy, Physical Therapy. Service 2026-02-05 at office (POS 11). Received 2026-03-19.

Approved
Billed
$132.00
1 line
Allowed
$81.84
contract rate applied
Plan pays
$41.84
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Christina Bowman
Member ID
UHC-36877-11
Date of birth
1976-04-24
Identity
Verified2 records, confidence 0.96
Claim record
CLMCLM-407135
Relationship
Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-6429
Coverage period
2024-06-01 to present
Deductible
$962.52 of $2,500.0039%
Out-of-pocket maximum
$3,711.76 of $10,000.0037%
Copays
office $40.00, specialist $75.00, emergency $250.00
Physical therapy visits
11 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
7650650246
Network
In network
Rendering NPI
7276240299
Location
Miami, FL · TIN 30-1447638
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$132.00$81.84$40.00$41.84Paid
Totals$132.00$81.84$40.00$41.84
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-394337
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-020687 (verified, link confidence 0.96).
EligibilityPassActive on 2026-02-05: CHOICE-PLUS-PPO (PPO), effective 2024-06-01.
Timely filingPassReceived 42 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Physical Therapy (7650650246).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 11 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: Heritage Physical Therapy2026-02-05 12:38

    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
$132.00
Plan discount
$50.16
contracted rate
Plan paid
$41.84
You may owe
$40.00
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