Claims workbench/CLM-2026-000518
Professional claim · CMS-1500 · EDI 837P

CLM-2026-000518

Harbor Rehabilitation Center, Physical Therapy. Service 2025-08-29 at office (POS 11). Received 2026-01-27.

Denied
Billed
$166.00
1 line
Allowed
$102.92
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Jeremy Watkins
Member ID
UHC-96761-53
Date of birth
1971-01-23
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-426166
Relationship
Self, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-1509
Coverage period
2024-06-01 to present
Deductible
$2,683.17 of $3,500.0077%
Out-of-pocket maximum
$504.89 of $10,500.005%
Copays
office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits
8 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
1139592160
Network
In network
Rendering NPI
1508752676
Location
Mesa, AZ · TIN 48-8489623
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—21$166.00$102.92——DeniedCO29
Totals$166.00$102.92——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. Z47.1 Aftercare following joint replacement surgery
Claim header
Patient account
PA-278913
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-007988 (verified, link confidence 1.00).
EligibilityPassActive on 2025-08-29: - (PPO), effective 2024-06-01.
Timely filingFailCO29Received 151 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Rehabilitation Center (1139592160).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 8 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Harbor Rehabilitation Center2025-08-29 14:27

    Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.

  • SystemSystem: Claims system2026-01-27 01:34

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Timely filing: Received 151 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied 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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity