Claims workbench/CLM-2026-031511
Professional claim · CMS-1500 · Paper

CLM-2026-031511

Desert Rehabilitation Center, Physical Therapy. Service 2026-02-01 at office (POS 11). Received 2026-02-26.

Approved
Billed
$272.00
1 line
Allowed
$168.64
contract rate applied
Plan pays
$138.64
approved
Member owes
$30.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Eugene Anderson
Member ID
UHC-70469-53
Date of birth
1963-08-20
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-422868
Relationship
Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group NULL
Coverage period
2025-05-01 to present
Deductible
$12.49 of $1,000.001%
Out-of-pocket maximum
$45.13 of $3,000.002%
Copays
office $30.00, specialist $60.00, emergency $350.00
Physical therapy visits
14 of 20 used

Provider

Billing and rendering

Billing provider
Desert Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
1142322233
Network
In network
Rendering NPI
7382013218
Location
Mesa, AZ · TIN 33-5650925
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—41$272.00$168.64$30.00$138.64Paid
Totals$272.00$168.64$30.00$138.64
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-530156
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

CheckResultCodeDetail
Member identityPassAttached to MBR-015896 (verified, link confidence 0.99).
EligibilityPassActive on 2026-02-01: OPTIONS-PPO (PPO), effective 2025-05-01.
Timely filingPassReceived 25 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Rehabilitation Center (1142322233).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 14 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Desert Rehabilitation Center2026-02-01 09:08

    Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$272.00
Plan discount
$103.36
contracted rate
Plan paid
$138.64
You may owe
$30.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0307782026-04-03Heritage Community Hospital$3,354.00Approved

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.

Review queueMember identity