Professional claim · CMS-1500 · EDI 837P
CLM-2026-023553
Mesa Physical Therapy, Physical Therapy. Service 2026-04-20 at office (POS 11). Received 2026-05-09.
Approved
Billed
$286.00
2 lines
Allowed
$177.32
contract rate applied
Plan pays
$157.32
approved
Member owes
$20.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Megan Rice
- Member ID
- UHC-35388-29
- Date of birth
- 1941-01-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413469
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2502
- Coverage period
- 2023-02-01 to present
- Deductible
- $1,249.43 of $2,500.0050%
- Out-of-pocket maximum
- $257.34 of $10,000.003%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 5785282968
- Location
- Houston, TX · TIN 58-9513034
- 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 | — | 3 | 1 | $204.00 | $126.48 | $20.00 | $106.48 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $82.00 | $50.84 | $0.00 | $50.84 | Paid |
| Totals | $286.00 | $177.32 | $20.00 | $157.32 | ||||||
Diagnoses (ICD-10-CM)
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-329797
- 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-001914 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-20: OPTIONS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 19 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 3 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 Therapy2026-04-20 09:02
Patient seen for aftercare following joint replacement surgery.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$286.00
Plan discount
$108.68
contracted rate
Plan paid
$157.32
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-2026-023554 | 2026-04-20 | Pinecrest Physical Therapy | $286.00 | 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.