Claims workbench/CLM-2026-023256
Professional claim · CMS-1500 · EDI 837P

CLM-2026-023256

Unity Physical Therapy, Physical Therapy. Service 2026-03-25 at office (POS 11). Received 2026-04-25.

Denied
Billed
$324.00
1 line
Allowed
$200.88
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Billy Gardner
Member ID
UHC-78599-36
Date of birth
1991-12-14
Identity
Verified2 records, confidence 0.97
Claim record
CLMCLM-418298
Relationship
Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-8544
Coverage period
2021-08-01 to 2026-03-08
Deductible
$711.24 of $2,500.0028%
Out-of-pocket maximum
$715.05 of $5,000.0014%
Copays
office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits
3 of 20 used

Provider

Billing and rendering

Billing provider
Unity Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
8723835475
Network
In network
Rendering NPI
7790299466
Location
Houston, TX · TIN 17-6644986
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—41$324.00$200.88——DeniedCO27
Totals$324.00$200.88——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
  • 2. Z47.1 Aftercare following joint replacement surgery
Claim header
Patient account
PA-274974
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-019757 (verified, link confidence 0.97).
EligibilityFailCO27Date of service 2026-03-25 is after coverage terminated on 2026-03-08.
Expenses incurred after coverage terminated
Timely filingPassReceived 31 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Physical Therapy (8723835475).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 3 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: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Unity Physical Therapy2026-03-25 11:41

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

  • SystemSystem: Claims system2026-04-25 01:45

  • AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-25 11:47

    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

  1. Rules engineDenied2026-10-21 13:43
    Eligibility: Date of service 2026-03-25 is after coverage terminated on 2026-03-08.

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queueMember identity