Claims workbench/CLM-2026-005636

Professional claim · CMS-1500 · EDI 837P

CLM-2026-005636

Heritage Rehabilitation Center, Physical Therapy. Service 2026-09-12 at office (POS 11). Received 2026-10-10.

Denied

Billed

$176.00

2 lines

Allowed

$109.12

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

LIM

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Cheryl Simmons
Member ID: UHC-92867-01
Date of birth: 2002-12-17
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-404129
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-7521
Coverage period: 2022-07-01 to present
Deductible: $2,231.54 of $3,500.0064%
Out-of-pocket maximum: $2,605.31 of $14,000.0019%
Copays: office $40.00, specialist $75.00, emergency $150.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI: 6638399413
Network: In network
Rendering NPI: 9107784735
Location: Nashville, TN · TIN 93-4440762
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	59	2	1	$120.00	$74.40	—	—	DeniedLIM
2	97140	Manual therapy, 15 minutes	59	1	2	$56.00	$34.72	—	—	DeniedLIM
Totals						$176.00	$109.12	—	—

Diagnoses (ICD-10-CM)

1. Z47.1 Aftercare following joint replacement surgeryprincipal
2. M75.100 Unspecified rotator cuff tear, unspecified shoulder

Claim header

Patient account: PA-532798
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-017566 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-12: CHOICE-PLUS-PPO (PPO), effective 2022-07-01.
Timely filing	Pass		Received 28 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Heritage Rehabilitation Center (6638399413).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Fail	LIM	Physical therapy visits used 20 of 20 for the plan year. Benefit limit reached
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Rehabilitation Center2026-09-12 12:33
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-10-10 05:58
Member has used the annual physical-therapy visit benefit for the plan year.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-10 14:40
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit limits: Physical therapy visits used 20 of 20 for the plan year.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-006939	2026-07-15	Pinecrest Medical Group	$198.00	Approved
CLM-2026-032626	2026-01-21	Valley Heart Institute	$501.00	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

DeniedLIMscenario: Benefit limit

Annual visit limit exhausted.

Review queue Member identity