Professional claim · CMS-1500 · EDI 837P
CLM-2026-019188
Pinecrest Physical Therapy, Physical Therapy. Service 2026-02-16 at office (POS 11). Received 2026-02-22.
Approved
Billed
$287.00
3 lines
Allowed
$177.94
contract rate applied
Plan pays
$152.94
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Edward Delgado
- Member ID
- UHC-98565-10
- Date of birth
- 1986-01-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-406787
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4393
- Coverage period
- 2025-10-01 to 2026-08-12
- Deductible
- $799.16 of $1,000.0080%
- Out-of-pocket maximum
- $1,320.18 of $3,000.0044%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 3283829786
- Location
- Miami, FL · TIN 41-8840384
- Authorisation / referral
- none / REF733346
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 | $165.00 | $102.30 | $25.00 | $77.30 | Paid |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $48.00 | $29.76 | $0.00 | $29.76 | Paid |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1,2 | $74.00 | $45.88 | $0.00 | $45.88 | Paid |
| Totals | $287.00 | $177.94 | $25.00 | $152.94 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
Claim header
- Patient account
- PA-479342
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004046 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-16: CORE-HMO (HMO), effective 2025-10-01, terms 2026-08-12. | |
| Timely filing | Pass | Received 6 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 Pinecrest Physical Therapy (8748441127). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 15 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Physical Therapy2026-02-16 16:11
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
$287.00
Plan discount
$109.06
contracted rate
Plan paid
$152.94
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033040 | 2026-10-04 | Canyon Medical Group | $736.00 | Denied |
| CLM-2026-018307 | 2026-08-06 | Unity Digestive Health Center | $321.00 | Approved |
| CLM-2026-022309 | 2026-02-15 | Summit Endocrine Associates | $659.00 | 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.