Claims workbench/CLM-2026-018266

Professional claim · CMS-1500 · EDI 837P

CLM-2026-018266

Sunrise Physical Therapy, Physical Therapy. Service 2026-03-23 at office (POS 11). Received 2026-04-16.

Denied

Billed

$538.00

3 lines

Allowed

$333.56

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27, LIM

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Judy Burns
Member ID: UHC-13174-98
Date of birth: 1980-12-09
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-415698
Relationship: Spouse, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-1473
Coverage period: 2021-06-01 to 2026-03-17
Deductible: $236.20 of $1,000.0024%
Out-of-pocket maximum: $286.51 of $3,000.0010%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 7462471310
Network: In network
Rendering NPI: 1199875117
Location: Tampa, FL · TIN 63-7352988
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	—	4	1	$308.00	$190.96	—	—	DeniedCO27
2	97014	Electrical stimulation, unattended	—	1	2	$57.00	$35.34	—	—	DeniedCO27
3	97161	PT evaluation, low complexity	—	1	2	$173.00	$107.26	—	—	DeniedCO27
Totals						$538.00	$333.56	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. Z47.1 Aftercare following joint replacement surgery

Claim header

Patient account: PA-581387
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	Pass		Attached to MBR-007661 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-03-23 is after coverage terminated on 2026-03-17. Expenses incurred after coverage terminated
Timely filing	Pass		Received 24 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 Sunrise Physical Therapy (7462471310).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Fail	LIM	Physical therapy visits used 20 of 20 for the plan year. Benefit limit reached
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: Sunrise Physical Therapy2026-03-23 15:17
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-04-16 00:11
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-16 14:43
Called the provider office; awaiting documentation.

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
Eligibility: Date of service 2026-03-23 is after coverage terminated on 2026-03-17. Benefit limits: Physical therapy visits used 20 of 20 for the plan year.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-021084	2026-08-13	Pinecrest Bone and Joint Center	$9,739.00	Denied
CLM-2026-031335	2026-08-08	Meadow Bone and Joint Center	$236.00	Denied
CLM-2026-032125	2025-12-31	Lakeside Digestive Health Center	$1,758.00	Approved
CLM-2026-010350	2026-01-21	Mesa Clinical Laboratories	$174.00	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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity