Professional claim · CMS-1500 · EDI 837P
CLM-2026-024812
Harbor Physical Therapy, Physical Therapy. Service 2026-08-23 at office (POS 11). Received 2026-08-27.
Approved
Billed
$340.00
1 line
Allowed
$210.80
contract rate applied
Plan pays
$170.80
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Eric Schmidt
- Member ID
- UHC-94650-89
- Date of birth
- 1945-11-23
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-416393
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9328
- Coverage period
- 2024-08-01 to present
- Deductible
- $142.32 of $1,000.0014%
- Out-of-pocket maximum
- $599.62 of $4,000.0015%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 2909043855
- Location
- Miami, FL · TIN 59-6364489
- 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 | $340.00 | $210.80 | $40.00 | $170.80 | Paid |
| Totals | $340.00 | $210.80 | $40.00 | $170.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
Claim header
- Patient account
- PA-757881
- 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-005264 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-23: MEDICARE-ADV-A (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 4 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 Harbor Physical Therapy (9493518267). | |
| 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: Harbor Physical Therapy2026-08-23 09:07
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
$340.00
Plan discount
$129.20
contracted rate
Plan paid
$170.80
You may owe
$40.00
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-2026-024813 | 2026-08-23 | Harbor Physical Therapy | $340.00 | Denied |
| CLM-2026-026879 | 2026-08-04 | Summit Community Hospital | $1,383.00 | Approved |
| CLM-2026-022204 | 2026-07-24 | Sunrise Counseling Center | $434.00 | Approved |
| CLM-2026-020821 | 2026-05-22 | Sunrise Cardiovascular Associates | $8,850.00 | Approved |
| CLM-2026-011139 | 2025-12-15 | Mesa Regional Medical Center | $328.00 | 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
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.