Claims workbench/CLM-2026-013751
Professional claim · CMS-1500 · EDI 837P

CLM-2026-013751

Heritage Rehabilitation Center, Physical Therapy. Service 2026-06-16 at office (POS 11). Received 2026-07-18.

Pended
Billed
$407.00
2 lines
Allowed
$252.34
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
CO16
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

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-1263
Coverage period
2024-05-01 to present
Deductible
$164.33 of $1,000.0016%
Out-of-pocket maximum
$1,570.49 of $4,000.0039%
Copays
office $40.00, specialist $40.00, emergency $150.00
Physical therapy visits
8 of 20 used

Provider

Billing and rendering

Billing provider
Heritage Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
6638399413
Network
In network
Rendering NPI
3572663466
Location
Nashville, TN · TIN 93-4440762
Authorisation / referral
none / REF512405

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—41$372.00$230.64——PendedCO16
297014Electrical stimulation, unattended—12$35.00$21.70——PendedCO16
Totals$407.00$252.34——
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
  • 2. M25.561 Pain in right knee
Claim header
Patient account
PA-593646
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 identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityPassActive on 2026-06-16: NAVIGATE-HMO (HMO), effective 2024-05-01.
Timely filingPassReceived 32 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 8 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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Rehabilitation Center2026-06-16 18:09

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

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity.

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.

Review queue