Professional claim · CMS-1500 · Paper
CLM-2026-017563
Meadow Physical Therapy, Physical Therapy. Service 2026-08-13 at office (POS 11). Received 2026-09-07.
ApprovedOut of network
Billed
$519.00
3 lines
Allowed
$233.55
contract rate applied
Plan pays
$203.55
approved
Member owes
$30.00
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
- Susan Hill
- Member ID
- UHC-93575-40
- Date of birth
- 1945-07-03
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-421279
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8427
- Coverage period
- 2025-10-01 to present
- Deductible
- $218.77 of $500.0044%
- Out-of-pocket maximum
- $217.17 of $2,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 5895454770
- Location
- Denver, CO · TIN 57-2119772
- 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 | — | 3 | 1 | $276.00 | $124.20 | $30.00 | $94.20 | Paid |
| 2 | 97161 | PT evaluation, low complexity | 25 | 1 | 1 | $190.00 | $85.50 | $0.00 | $85.50 | Paid |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $53.00 | $23.85 | $0.00 | $23.85 | Paid |
| Totals | $519.00 | $233.55 | $30.00 | $203.55 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-293363
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008052 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-13: NULL (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 25 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 14 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: Meadow Physical Therapy2026-08-13 12:27
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$519.00
Plan discount
$285.45
out-of-network allowance
Plan paid
$203.55
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025387 | 2026-03-30 | Evergreen Rehabilitation Center | $453.00 | 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.