Professional claim · CMS-1500 · EDI 837P
CLM-2026-018128
Evergreen Rehabilitation Center, Physical Therapy. Service 2026-06-14 at office (POS 11). Received 2026-07-24.
Approved
Billed
$272.00
2 lines
Allowed
$168.64
contract rate applied
Plan pays
$148.64
approved
Member owes
$20.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Noah West
- Member ID
- UHC-54131-68
- Date of birth
- 2008-12-14
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-401194
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2799
- Coverage period
- 2022-08-01 to present
- Deductible
- $448.41 of $1,000.0045%
- Out-of-pocket maximum
- $1,331.69 of $3,000.0044%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 9149209782
- Location
- Phoenix, AZ · TIN 14-6171767
- 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 | — | 2 | 1 | $178.00 | $110.36 | $20.00 | $90.36 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $94.00 | $58.28 | $0.00 | $58.28 | Paid |
| Totals | $272.00 | $168.64 | $20.00 | $148.64 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
Claim header
- Patient account
- PA-305913
- 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-026836 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-14: SELECT-EPO (EPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 40 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 Evergreen Rehabilitation Center (8258289502). | |
| 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: Evergreen Rehabilitation Center2026-06-14 11:16
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
$272.00
Plan discount
$103.36
contracted rate
Plan paid
$148.64
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004410 | 2026-06-26 | Heritage Community Hospital | $4,860.00 | Needs review |
| CLM-2026-004409 | 2026-06-26 | Meadow Regional Medical Center | $4,860.00 | Approved |
| CLM-2026-018551 | 2026-04-13 | Pinecrest Reference Lab | $43.00 | 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.