Professional claim · CMS-1500 · EDI 837P
CLM-2026-031222
Heritage Rehabilitation Center, Physical Therapy. Service 2026-08-08 at office (POS 11). Received 2026-09-12.
Approved
Billed
$439.00
3 lines
Allowed
$272.18
contract rate applied
Plan pays
$247.18
approved
Member owes
$25.00
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
- Theresa Torres
- Member ID
- UHC-55258-87
- Date of birth
- 1990-03-18
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-408201
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8404
- Coverage period
- 2024-11-01 to present
- Deductible
- $213.86 of $500.0043%
- Out-of-pocket maximum
- $475.97 of $1,500.0032%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 9849775165
- Location
- Nashville, TN · TIN 93-4440762
- Authorisation / referral
- none / REF362107
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 | $130.00 | $80.60 | $25.00 | $55.60 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $249.00 | $154.38 | $0.00 | $154.38 | Paid |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1,2 | $60.00 | $37.20 | $0.00 | $37.20 | Paid |
| Totals | $439.00 | $272.18 | $25.00 | $247.18 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-171378
- 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-002788 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-08: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 35 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 8 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: Heritage Rehabilitation Center2026-08-08 10:50
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$439.00
Plan discount
$166.82
contracted rate
Plan paid
$247.18
You may owe
$25.00
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-2026-006852 | 2026-09-22 | Northgate Internal Medicine Associates | $405.00 | Needs review |
| CLM-2026-030030 | 2026-04-20 | Riverside Orthopedic Specialists | $432.00 | Approved |
| CLM-2026-026599 | 2025-12-26 | Unity Family Practice | $25.00 | 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.