Professional claim · CMS-1500 · EDI 837P
CLM-2026-025647
Evergreen Rehabilitation Center, Physical Therapy. Service 2025-12-22 at office (POS 11). Received 2026-01-07.
Approved
Billed
$276.00
1 line
Allowed
$171.12
contract rate applied
Plan pays
$141.12
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Frank Soto
- Member ID
- UHC-00758-40
- Date of birth
- 1946-10-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400355
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6983
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,495.12 of $3,500.0071%
- Out-of-pocket maximum
- $3,051.23 of $7,000.0044%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 5511860343
- Location
- Phoenix, AZ · TIN 14-6171767
- 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 | $276.00 | $171.12 | $30.00 | $141.12 | Paid |
| Totals | $276.00 | $171.12 | $30.00 | $141.12 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-440001
- 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-001943 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 16 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 Evergreen Rehabilitation Center (8258289502). | |
| 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: Evergreen Rehabilitation Center2025-12-22 17:02
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
$276.00
Plan discount
$104.88
contracted rate
Plan paid
$141.12
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.