Claims workbench/CLM-2026-002487

Professional claim · CMS-1500 · EDI 837P

CLM-2026-002487

Meadow Physical Therapy, Physical Therapy. Service 2026-08-24 at office (POS 11). Received 2026-10-14.

Needs review

Billed

$162.00

1 line

Allowed

$100.44

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Keith Cruz
Member ID: none on golden record
Date of birth: 1946-01-14
Identity: Verified2 records, confidence 1.00
Claim record: CLMCLM-432082
Relationship: Spouse, San Antonio, TX

Coverage and accumulators

Found by name and date of birth

Plan: CORE-HMO HMO group GRP-8444
Coverage period: 2023-04-01 to present
Deductible: $2,983.62 of $3,500.0085%
Out-of-pocket maximum: $3,854.22 of $10,500.0037%
Copays: office $40.00, specialist $60.00, emergency $150.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Meadow Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 7881128434
Network: In network
Rendering NPI: 4338336116
Location: Houston, TX · TIN 60-4048186
Authorisation / referral: none / REF565116

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	$162.00	$100.44	—	—	Review
Totals						$162.00	$100.44	—	—

Diagnoses (ICD-10-CM)

1. Z47.1 Aftercare following joint replacement surgeryprincipal
2. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-762757
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-016403 (verified, link confidence 1.00).
Eligibility	Note		Active on 2026-08-24: CORE-HMO (HMO), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 51 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-002486, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Meadow Physical Therapy (7881128434).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Note		Physical therapy visits used 19 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: Meadow Physical Therapy2026-08-24 18:12
Patient seen for aftercare following joint replacement surgery. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-10-14 04:34
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Eligibility: Active on 2026-08-24: CORE-HMO (HMO), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Same member, date of service and procedures as CLM-2026-002486, billed by a different provider. Benefit limits: Physical therapy visits used 19 of 20.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-002486	2026-08-24	Desert Rehabilitation Center	$162.00	Approved
CLM-2026-019351	2026-02-21	Sunrise Medical Group	$426.00	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

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity