Claims workbench/CLM-2026-024350

Professional claim · CMS-1500 · EDI 837P

CLM-2026-024350

Sunrise Physical Therapy, Physical Therapy. Service 2025-12-20 at office (POS 11). Received 2026-01-07.

Approved

Billed

$323.00

2 lines

Allowed

$200.26

contract rate applied

Plan pays

$180.26

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: Amber Banks
Member ID: UHC-25427-90
Date of birth: 1975-11-16
Identity: Verified3 records, confidence 1.00
Claim record: CLMCLM-429630
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-6796
Coverage period: 2023-09-01 to present
Deductible: $871.93 of $2,500.0035%
Out-of-pocket maximum: $3,059.83 of $7,500.0041%
Copays: office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 7462471310
Network: In network
Rendering NPI: 9757048928
Location: Tampa, FL · TIN 63-7352988
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	$284.00	$176.08	$20.00	$156.08	Paid
2	97014	Electrical stimulation, unattended	—	1	1,2	$39.00	$24.18	$0.00	$24.18	Paid
Totals						$323.00	$200.26	$20.00	$180.26

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-518500
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Detail
Member identity	Pass	Attached to MBR-002034 (verified, link confidence 1.00).
Eligibility	Pass	Active on 2025-12-20: OPTIONS-PPO (PPO), effective 2023-09-01.
Timely filing	Pass	Received 18 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 Sunrise Physical Therapy (7462471310).
Medical necessity	Pass	Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass	No bundling conflicts.
Benefit limits	Note	Physical therapy visits used 18 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: Sunrise Physical Therapy2025-12-20 17:19
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-01-07 03:38
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-07 09:58
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-518500.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.

Explanation of benefits

What the member will see

Amount billed

$323.00

Plan discount

$122.74

contracted rate

Plan paid

$180.26

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 13:43
Benefit limits: Physical therapy visits used 18 of 20.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-020612	2026-01-24	Heritage Medical Group	$14.00	Approved

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity