Claims workbench/CLM-2026-015161

Professional claim · CMS-1500 · EDI 837P

CLM-2026-015161

Heritage Rehabilitation Center, Physical Therapy. Service 2026-05-04 at office (POS 11). Received 2026-06-20.

Denied

Billed

$252.00

2 lines

Allowed

$156.24

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Judy Payne
Member ID: UHC-70825-08
Date of birth: 1950-01-20
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-408468
Relationship: Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-8253
Coverage period: 2021-06-01 to present
Deductible: $1,658.10 of $2,500.0066%
Out-of-pocket maximum: $4,446.42 of $10,000.0044%
Copays: office $30.00, specialist $40.00, emergency $150.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI: 6638399413
Network: In network
Rendering NPI: 9155716175
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	$201.00	$124.62	—	—	DeniedCO18
2	97014	Electrical stimulation, unattended	—	1	1	$51.00	$31.62	—	—	DeniedCO18
Totals						$252.00	$156.24	—	—

Diagnoses (ICD-10-CM)

1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal

Claim header

Patient account: PA-171161
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-008585 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-05-04: OPTIONS-PPO (PPO), effective 2021-06-01.
Timely filing	Pass		Received 47 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-015160: same member, date of service, procedures and billing provider. Exact duplicate claim or service
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		Physical therapy visits used 15 of 20.
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Rehabilitation Center2026-05-04 16:18
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-06-20 06:09
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-20 17:21
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-015160: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-008361	2026-09-23	Desert Diagnostic Imaging	$137.00	Denied
CLM-2026-008360	2026-09-23	Desert Diagnostic Imaging	$137.00	Approved
CLM-2026-015160	2026-05-04	Heritage Rehabilitation Center	$252.00	Approved
CLM-2026-030256	2026-01-25	Meadow Cardiovascular Associates	$7,416.00	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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity