Professional claim · CMS-1500 · EDI 837P
CLM-2026-006957
Heritage Rehabilitation Center, Physical Therapy. Service 2026-08-17 at office (POS 11). Received 2026-08-22.
Pended
Billed
$431.00
2 lines
Allowed
$267.22
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
CO16, N30
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.
Coverage and accumulators
Eligibility
No coverage segment found for this member.
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 1324558562
- 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 | — | 3 | 1 | $192.00 | $119.04 | — | — | PendedCO16 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $239.00 | $148.18 | — | — | PendedCO16 |
| Totals | $431.00 | $267.22 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-873617
- 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 | Fail | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 5 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) | 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: Heritage Rehabilitation Center2026-08-17 15:47
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. Eligibility: No coverage segment found for the member ID on this claim.
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
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.