Claims workbench/CLM-2026-005021
Professional claim · CMS-1500 · Paper

CLM-2026-005021

Heritage Rehabilitation Center, Physical Therapy. Service 2026-05-09 at office (POS 11). Received 2026-05-15.

Approved
Billed
$246.00
1 line
Allowed
$152.52
contract rate applied
Plan pays
$127.52
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Jennifer Fisher
Member ID
UHC-26712-13
Date of birth
1993-11-23
Identity
Verified4 records, confidence 0.99
Claim record
CLMCLM-419494
Relationship
Child, Jacksonville, FL

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-8279
Coverage period
2022-04-01 to present
Deductible
$449.77 of $500.0090%
Out-of-pocket maximum
$202.82 of $1,000.0020%
Copays
office $25.00, specialist $60.00, emergency $150.00
Physical therapy visits
11 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
6638399413
Network
In network
Rendering NPI
6272796429
Location
Nashville, TN · TIN 93-4440762
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—31$246.00$152.52$25.00$127.52Paid
Totals$246.00$152.52$25.00$127.52
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
  • 2. M25.561 Pain in right knee
Claim header
Patient account
PA-354434
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-004704 (verified, link confidence 0.99).
EligibilityPassActive on 2026-05-09: OPTIONS-PPO (PPO), effective 2022-04-01.
Timely filingPassReceived 6 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Rehabilitation Center (6638399413).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 11 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Rehabilitation Center2026-05-09 14:49

    Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$246.00
Plan discount
$93.48
contracted rate
Plan paid
$127.52
You may owe
$25.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0294862026-01-08Harbor Imaging Center$2,630.00Denied

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity