Professional claim · CMS-1500 · EDI 837P
CLM-2026-012804
Valley Rehabilitation Center, Physical Therapy. Service 2026-07-30 at office (POS 11). Received 2026-08-08.
Denied
Billed
$208.00
2 lines
Allowed
$128.96
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- William Russell
- Member ID
- UHC-23538-66
- Date of birth
- 1965-03-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430050
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5009
- Coverage period
- 2024-05-01 to 2026-01-28
- Deductible
- $11.47 of $500.002%
- Out-of-pocket maximum
- $531.49 of $2,000.0027%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 6422185952
- Location
- Tempe, AZ · TIN 20-6528291
- 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 | $166.00 | $102.92 | — | — | DeniedCO27 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $42.00 | $26.04 | — | — | DeniedCO27 |
| Totals | $208.00 | $128.96 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
Claim header
- Patient account
- PA-985694
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011389 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-30 is after coverage terminated on 2026-01-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 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 Valley Rehabilitation Center (6713462326). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 15 of 20. | |
| 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: Valley Rehabilitation Center2026-07-30 11:48
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-08-08 00:04
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-30 is after coverage terminated on 2026-01-28.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002145 | 2025-12-31 | Riverside Bone and Joint Center | $186.00 | Needs review |
| CLM-2026-002144 | 2025-12-31 | Lakeside Bone and Joint Center | $186.00 | 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
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.