Professional claim · CMS-1500 · EDI 837P
CLM-2026-020537
Pinecrest Physical Therapy, Physical Therapy. Service 2026-01-16 at office (POS 11). Received 2026-03-02.
Approved
Billed
$591.00
3 lines
Allowed
$366.42
contract rate applied
Plan pays
$336.42
approved
Member owes
$30.00
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
- Amber Wright
- Member ID
- UHC-22849-60
- Date of birth
- 1939-02-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-414261
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2021-11-01 to 2026-08-28
- Deductible
- $43.75 of $500.009%
- Out-of-pocket maximum
- $397.42 of $1,000.0040%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 1410199917
- Location
- Austin, TX · TIN 13-9684371
- 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 | — | 4 | 1 | $324.00 | $200.88 | $30.00 | $170.88 | Paid |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $54.00 | $33.48 | $0.00 | $33.48 | Paid |
| 3 | 97161 | PT evaluation, low complexity | 25 | 1 | 2 | $213.00 | $132.06 | $0.00 | $132.06 | Paid |
| Totals | $591.00 | $366.42 | $30.00 | $336.42 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-546189
- 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-016847 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-16: NULL (PPO), effective 2021-11-01, terms 2026-08-28. | |
| Timely filing | Pass | Received 45 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 (8020189691). | |
| 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: Pinecrest Physical Therapy2026-01-16 11:36
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
$591.00
Plan discount
$224.58
contracted rate
Plan paid
$336.42
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 12:44Clean 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.