Claims workbench/CLM-2026-002997

Institutional claim · UB-04 · EDI 837I

CLM-2026-002997

Pinecrest Physical Therapy, Physical Therapy. Service 2026-09-08 at outpatient hospital (POS 22). Received 2026-10-02.

PendedIdentity on hold: CASE-000268

Billed

$6,768.00

1 line

Allowed

$3,722.40

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Betty Mendez
Member ID: none on golden record
Date of birth: 1998-09-03
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-409472
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: OPTIONS-PPO PPO group GRP-4762
Coverage period: 2022-11-01 to present
Deductible: $48.65 of $500.0010%
Out-of-pocket maximum: $829.41 of $2,000.0041%
Copays: office $40.00, specialist $75.00, emergency $250.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 8748441127
Network: In network
Rendering NPI: 8097672405
Location: Miami, FL · TIN 41-8840384
Authorisation / referral: PA2026409043 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	70553 rev 0610	MRI brain with and without contrast	—	3	1	$6,768.00	$3,722.40	—	—	PendedIDQ
Totals						$6,768.00	$3,722.40	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. Z47.1 Aftercare following joint replacement surgery

Claim header

Patient account: PA-122280
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	Fail	IDQ	Member record is in open steward case CASE-000268; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-09-08: OPTIONS-PPO (PPO), effective 2022-11-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 24 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026409043 on file for 70553.
Provider network	Pass		In-network provider Pinecrest Physical Therapy (8748441127).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Physical Therapy2026-09-08 17:16
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
SystemSystem: Claims system2026-10-02 03:01
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-02 10:09
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026409043_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-08 to 2026-12-07.
Itemized billitemized_PA-122280.pdf8 pages
Itemised statement totalling $6768.00 across 1 line.
Medical recordrecords_PA-122280.pdf10 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000268; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-08: OPTIONS-PPO (PPO), effective 2022-11-01. Coverage found by name and date of birth because the claim carried no usable member ID. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

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

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: Dx mismatch

Notes document medical necessity.

Review queue Member identity