Professional claim · CMS-1500 · Provider portal
CLM-2026-030519
Heritage Rehabilitation Center, Physical Therapy. Service 2025-11-22 at office (POS 11). Received 2026-01-04.
Approved
Billed
$262.00
3 lines
Allowed
$162.44
contract rate applied
Plan pays
$142.44
approved
Member owes
$20.00
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
- Dorothy Hayes
- Member ID
- UHC-27529-31
- Date of birth
- 2007-11-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424127
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5842
- Coverage period
- 2023-09-01 to 2026-01-21
- Deductible
- $1,988.51 of $3,500.0057%
- Out-of-pocket maximum
- $3,896.70 of $10,500.0037%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 2787389867
- Location
- Nashville, TN · TIN 93-4440762
- 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 | — | 2 | 1 | $150.00 | $93.00 | $20.00 | $73.00 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1 | $55.00 | $34.10 | $0.00 | $34.10 | Paid |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $57.00 | $35.34 | $0.00 | $35.34 | Paid |
| Totals | $262.00 | $162.44 | $20.00 | $142.44 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-989471
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001234 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-22: MEDICARE-ADV-A (MA), effective 2023-09-01, terms 2026-01-21. | |
| Timely filing | Pass | Received 43 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 Heritage Rehabilitation Center (6638399413). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 6 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: Heritage Rehabilitation Center2025-11-22 16:26
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
$262.00
Plan discount
$99.56
contracted rate
Plan paid
$142.44
You may owe
$20.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030520 | 2025-11-22 | Heritage Rehabilitation Center | $262.00 | Denied |
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.