Claims workbench/CLM-2026-008676
Professional claim · CMS-1500 · EDI 837P

CLM-2026-008676

Lakeside Physical Therapy, Physical Therapy. Service 2026-03-09 at office (POS 11). Received 2026-03-12.

Denied
Billed
$252.00
1 line
Allowed
$156.24
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Mariana Ortega
Member ID
UHC-09499-92
Date of birth
1999-07-03
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-406708
Relationship
Self, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-8993
Coverage period
2023-09-01 to 2026-02-13
Deductible
$421.15 of $500.0084%
Out-of-pocket maximum
$481.54 of $1,000.0048%
Copays
office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits
1 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
9861124797
Network
In network
Rendering NPI
1845793748
Location
Houston, TX · TIN 40-0662041
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—41$252.00$156.24——DeniedCO27
Totals$252.00$156.24——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
Claim header
Patient account
PA-855653
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

CheckResultCodeDetail
Member identityPassAttached to MBR-019202 (verified, link confidence 0.97).
EligibilityFailCO27Date of service 2026-03-09 is after coverage terminated on 2026-02-13.
Expenses incurred after coverage terminated
Timely filingPassReceived 3 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Lakeside Physical Therapy (9861124797).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 1 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Therapy2026-03-09 09:57

    Patient seen for pain in right knee.

  • SystemSystem: Claims system2026-03-12 06:37

  • AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-12 09:42

    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

  1. Rules engineDenied2026-10-21 13:43
    Eligibility: Date of service 2026-03-09 is after coverage terminated on 2026-02-13.

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

Denied 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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queueMember identity