Claims workbench/CLM-2026-019594
Professional claim · CMS-1500 · Paper

CLM-2026-019594

Evergreen Rehabilitation Center, Physical Therapy. Service 2026-02-20 at office (POS 11). Received 2026-03-07.

Denied
Billed
$258.00
1 line
Allowed
$159.96
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
LIM
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Arjun Crawford
Member ID
UHC-35273-61
Date of birth
1971-06-23
Identity
Verified5 records, confidence 1.00
Claim record
CLMCLM-431210
Relationship
Self, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-2439
Coverage period
2021-04-01 to 2026-02-27
Deductible
$232.70 of $500.0047%
Out-of-pocket maximum
$643.31 of $2,000.0032%
Copays
office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI
8258289502
Network
In network
Rendering NPI
4931143307
Location
Phoenix, AZ · TIN 14-6171767
Authorisation / referral
none / REF123173

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—31$258.00$159.96——DeniedLIM
Totals$258.00$159.96——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
  • 2. M25.561 Pain in right knee
Claim header
Patient account
PA-649456
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-018027 (verified, link confidence 1.00).
EligibilityPassActive on 2026-02-20: NAVIGATE-HMO (HMO), effective 2021-04-01, terms 2026-02-27.
Timely filingPassReceived 15 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Rehabilitation Center (8258289502).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsFailLIMPhysical therapy visits used 22 of 20 for the plan year.
Benefit limit reached
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: Evergreen Rehabilitation Center2026-02-20 13:21

    Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-03-07 06:16

    Member has used the annual physical-therapy visit benefit for the plan year.

  • AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-07 17:01

    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

  1. Rules engineDenied2026-10-21 13:43
    Benefit limits: Physical therapy visits used 22 of 20 for the plan year.

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

DeniedLIMscenario: Benefit limit

Annual visit limit exhausted.

Review queueMember identity