Professional claim · CMS-1500 · EDI 837P
CLM-2026-022733
Pinecrest Physical Therapy, Physical Therapy. Service 2026-02-03 at office (POS 11). Received 2026-02-24.
Approved
Billed
$486.00
3 lines
Allowed
$301.32
contract rate applied
Plan pays
$271.32
approved
Member owes
$30.00
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
- Jonathan Rivera
- Member ID
- UHC-42719-76
- Date of birth
- 1953-04-10
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-425904
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8308
- Coverage period
- 2024-03-01 to present
- Deductible
- $75.21 of $1,000.008%
- Out-of-pocket maximum
- $421.19 of $2,000.0021%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 9749185754
- 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 | $252.00 | $156.24 | $30.00 | $126.24 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $182.00 | $112.84 | $0.00 | $112.84 | Paid |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $52.00 | $32.24 | $0.00 | $32.24 | Paid |
| Totals | $486.00 | $301.32 | $30.00 | $271.32 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-216912
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015624 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-02-03: NAVIGATE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 21 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 | Note | Physical therapy visits used 19 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 Therapy2026-02-03 15:01
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
$486.00
Plan discount
$184.68
contracted rate
Plan paid
$271.32
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 12:44Benefit limits: Physical therapy visits used 19 of 20.
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.