Professional claim · CMS-1500 · EDI 837P
CLM-2026-031773
Mesa Physical Therapy, Physical Therapy. Service 2026-03-02 at office (POS 11). Received 2026-03-26.
Approved
Billed
$252.00
1 line
Allowed
$156.24
contract rate applied
Plan pays
$131.24
approved
Member owes
$25.00
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
- Angela Nichols
- Member ID
- UHC-66882-67
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406212
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2512
- Coverage period
- 2025-10-01 to present
- Deductible
- $2,066.33 of $2,500.0083%
- Out-of-pocket maximum
- $1,926.63 of $7,500.0026%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 5720231351
- Network
- In network
- Rendering NPI
- 4107963926
- Location
- Scottsdale, AZ · TIN 18-6108832
- 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 | $252.00 | $156.24 | $25.00 | $131.24 | Paid |
| Totals | $252.00 | $156.24 | $25.00 | $131.24 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-701123
- 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-022099 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-02: NULL (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 24 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 Mesa Physical Therapy (5720231351). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 18 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: Mesa Physical Therapy2026-03-02 18:43
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
$252.00
Plan discount
$95.76
contracted rate
Plan paid
$131.24
You may owe
$25.00
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 18 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.