Claims workbench/CLM-2026-003513

Professional claim · CMS-1500 · EDI 837P

CLM-2026-003513

Lakeside Physical Therapy, Physical Therapy. Service 2025-09-01 at office (POS 11). Received 2026-03-21.

Denied

Billed

$403.00

2 lines

Allowed

$249.86

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Benjamin Fuller
Member ID: UHC-11971-67
Date of birth: 1964-03-15
Identity: Verified6 records, confidence 1.00
Claim record: CLMCLM-422727
Relationship: Spouse, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-7658
Coverage period: 2023-04-01 to present
Deductible: $2,560.29 of $3,500.0073%
Out-of-pocket maximum: $1,098.62 of $10,500.0010%
Copays: office $25.00, specialist $40.00, emergency $350.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 2744323421
Network: In network
Rendering NPI: 9995082622
Location: Minneapolis, MN · TIN 46-4889069
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	—	2	1	$174.00	$107.88	—	—	DeniedCO29
2	97161	PT evaluation, low complexity	—	1	1	$229.00	$141.98	—	—	DeniedCO29
Totals						$403.00	$249.86	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal

Claim header

Patient account: PA-837183
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-021063 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2025-09-01: MEDICARE-ADV-A (MA), effective 2023-04-01.
Timely filing	Fail	CO29	Received 201 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Lakeside Physical Therapy (2744323421).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		Physical therapy visits used 5 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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Physical Therapy2025-09-01 15:26
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-03-21 01:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-21 14:28
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 201 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-001252	2026-05-23	Heritage Medical Group	$184.00	Approved
CLM-2026-017129	2026-04-25	Pinecrest Regional Medical Center	$2,959.00	Approved
CLM-2026-023203	2026-04-18	Sunrise Heart Institute	$317.00	Approved
CLM-2026-021894	2026-04-15	Riverside Primary Care Associates	$219.00	Approved

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

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity