Claims workbench/CLM-2026-021432
Professional claim · CMS-1500 · EDI 837P

CLM-2026-021432

Mesa Physical Therapy, Physical Therapy. Service 2026-08-19 at office (POS 11). Received 2026-09-11.

Approved
Billed
$332.00
1 line
Allowed
$205.84
contract rate applied
Plan pays
$185.84
approved
Member owes
$20.00
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
Nicholas Hughes
Member ID
UHC-36357-55
Date of birth
1972-12-17
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-420108
Relationship
Self, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan
N/A PPO group -
Coverage period
2021-10-01 to present
Deductible
$752.14 of $2,500.0030%
Out-of-pocket maximum
$995.89 of $5,000.0020%
Copays
office $20.00, specialist $50.00, emergency $150.00
Physical therapy visits
13 of 20 used

Provider

Billing and rendering

Billing provider
Mesa Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
7870543981
Network
In network
Rendering NPI
6661272768
Location
Houston, TX · TIN 58-9513034
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—41$332.00$205.84$20.00$185.84Paid
Totals$332.00$205.84$20.00$185.84
Diagnoses (ICD-10-CM)
  • 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-232918
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

CheckResultCodeDetail
Member identityPassAttached to MBR-015127 (verified, link confidence 1.00).
EligibilityPassActive on 2026-08-19: N/A (PPO), effective 2021-10-01.
Timely filingPassReceived 23 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Physical Therapy (7870543981).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 13 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Mesa Physical Therapy2026-08-19 13:15

    Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$332.00
Plan discount
$126.16
contracted rate
Plan paid
$185.84
You may owe
$20.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean 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.

Review queueMember identity