Claims workbench/CLM-2026-004068

Professional claim · CMS-1500 · EDI 837P

CLM-2026-004068

Harbor Rehabilitation Center, Physical Therapy. Service 2025-08-15 at office (POS 11). Received 2026-02-16.

Denied

Billed

$283.00

3 lines

Allowed

$175.46

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

N30, CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Kyle Burns
Member ID: UHC-52612-93
Date of birth: 1946-02-23
Identity: Verified5 records, confidence 0.96
Claim record: CLMCLM-421780
Relationship: Self, Tucson, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-7479
Coverage period: 2025-11-01 to present
Deductible: $795.68 of $1,500.0053%
Out-of-pocket maximum: $2,237.66 of $4,500.0050%
Copays: office $20.00, specialist $40.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Harbor Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI: 1139592160
Network: In network
Rendering NPI: 6982236435
Location: Mesa, AZ · TIN 48-8489623
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	$164.00	$101.68	—	—	DeniedN30
2	97140	Manual therapy, 15 minutes	—	1	1	$89.00	$55.18	—	—	DeniedN30
3	97014	Electrical stimulation, unattended	—	1	1,2	$30.00	$18.60	—	—	DeniedN30
Totals						$283.00	$175.46	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. Z47.1 Aftercare following joint replacement surgery

Claim header

Patient account: PA-946589
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-005752 (verified, link confidence 0.96).
Eligibility	Fail	N30	Date of service 2025-08-15 is before coverage effective date 2025-11-01. Patient ineligible for this service
Timely filing	Fail	CO29	Received 185 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 Harbor Rehabilitation Center (1139592160).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		Physical therapy visits used 0 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: Harbor Rehabilitation Center2025-08-15 14:41
Follow-up for pain in right knee. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-02-16 04:55
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-16 16:10
Member services inquiry logged on this claim; member asked about the status of payment.

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
Eligibility: Date of service 2025-08-15 is before coverage effective date 2025-11-01. Timely filing: Received 185 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-033316	2026-03-04	Desert Internal Medicine Associates	$288.00	Denied
CLM-2026-033315	2026-03-04	Desert Internal Medicine Associates	$288.00	Approved
CLM-2026-028545	2026-02-11	Mesa Family Practice	$358.00	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