Professional claim · CMS-1500 · EDI 837P
CLM-2026-027875
Meadow Physical Therapy, Physical Therapy. Service 2026-05-16 at office (POS 11). Received 2026-06-26.
ApprovedOut of network
Billed
$463.00
2 lines
Allowed
$208.35
contract rate applied
Plan pays
$168.35
approved
Member owes
$40.00
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
- Ray Carpenter
- Member ID
- UHC-37527-46
- Date of birth
- 1968-04-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426526
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-2732
- Coverage period
- 2023-02-01 to present
- Deductible
- $423.09 of $1,000.0042%
- Out-of-pocket maximum
- $1,054.14 of $3,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 6888038554
- Location
- Denver, CO · TIN 57-2119772
- 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 | $285.00 | $128.25 | $40.00 | $88.25 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $178.00 | $80.10 | $0.00 | $80.10 | Paid |
| Totals | $463.00 | $208.35 | $40.00 | $168.35 | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
Claim header
- Patient account
- PA-505288
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030186 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-16: - (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 41 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Meadow Physical Therapy2026-05-16 16:57
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$463.00
Plan discount
$254.65
out-of-network allowance
Plan paid
$168.35
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030224 | 2026-04-04 | Sunrise Dermatology Clinic | $1,915.00 | 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.