Claims workbench/CLM-2026-001981

Professional claim · CMS-1500 · EDI 837P

CLM-2026-001981

Pinecrest Physical Therapy, Physical Therapy. Service 2026-01-08 at office (POS 11). Received 2026-02-03.

Needs review

Billed

$429.00

3 lines

Allowed

$265.98

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Zachary Carlson
Member ID: UHC-05862-91
Date of birth: 2003-10-23
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-403920
Relationship: Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-4758
Coverage period: 2022-10-01 to present
Deductible: $606.67 of $1,000.0061%
Out-of-pocket maximum: $1,237.71 of $3,000.0041%
Copays: office $40.00, specialist $75.00, emergency $250.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 8748441127
Network: In network
Rendering NPI: 5860295687
Location: Miami, FL · TIN 41-8840384
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	59	2	1	$168.00	$104.16	—	—	Review
2	97161	PT evaluation, low complexity	59	1	1,2	$206.00	$127.72	—	—	Review
3	97140	Manual therapy, 15 minutes	—	1	2	$55.00	$34.10	—	—	Review
Totals						$429.00	$265.98	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-650442
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-008576 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-08: CHOICE-PLUS-PPO (PPO), effective 2022-10-01.
Timely filing	Pass		Received 26 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 Pinecrest Physical Therapy (8748441127).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		Physical therapy visits used 16 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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Physical Therapy2026-01-08 17:42
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-02-03 02:54
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-03 10:39
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Medical recordrecords_PA-650442.pdf14 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-007259	2026-09-25	Valley Internal Medicine Associates	$452.00	Approved
CLM-2026-029699	2026-08-08	Unity Medical Group	$341.00	Needs review
CLM-2026-018395	2026-04-15	Sunrise Cardiovascular Associates	$5,174.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity