Professional claim · CMS-1500 · EDI 837P
CLM-2026-021133
Mesa Physical Therapy, Physical Therapy. Service 2026-02-10 at office (POS 11). Received 2026-02-25.
Approved
Billed
$531.00
2 lines
Allowed
$329.22
contract rate applied
Plan pays
$309.22
approved
Member owes
$20.00
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
- Carol Kelly
- Member ID
- UHC-09522-48
- Date of birth
- 1939-10-17
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418343
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1837
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,010.78 of $1,500.0067%
- Out-of-pocket maximum
- $1,392.24 of $3,000.0046%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 6689031543
- Location
- Houston, TX · TIN 58-9513034
- Authorisation / referral
- none / REF584663
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 | $320.00 | $198.40 | $20.00 | $178.40 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $211.00 | $130.82 | $0.00 | $130.82 | Paid |
| Totals | $531.00 | $329.22 | $20.00 | $309.22 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-534124
- 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-011970 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-10: CORE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 15 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 Mesa Physical Therapy (7870543981). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 11 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: Mesa Physical Therapy2026-02-10 18:35
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
$531.00
Plan discount
$201.78
contracted rate
Plan paid
$309.22
You may owe
$20.00
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-2026-014769 | 2026-07-11 | Northgate Internal Medicine Associates | $65.00 | Approved |
| CLM-2026-011091 | 2026-01-16 | Riverside Cardiovascular Associates | $8,535.00 | Needs review |
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.