Professional claim · CMS-1500 · EDI 837P
CLM-2026-024278
Heritage Rehabilitation Center, Physical Therapy. Service 2026-06-11 at office (POS 11). Received 2026-06-15.
Denied
Billed
$292.00
1 line
Allowed
$181.04
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Sean Turner
- Member ID
- UHC-59643-97
- Date of birth
- 1965-02-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-404716
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3848
- Coverage period
- 2025-12-01 to 2026-03-28
- Deductible
- $220.69 of $1,000.0022%
- Out-of-pocket maximum
- $453.43 of $2,000.0023%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 9575658775
- 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 | — | 4 | 1 | $292.00 | $181.04 | — | — | DeniedCO27 |
| Totals | $292.00 | $181.04 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-918222
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030143 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-11 is after coverage terminated on 2026-03-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 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 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 4 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Rehabilitation Center2026-06-11 16:34
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-06-15 04:58
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-11 is after coverage terminated on 2026-03-28.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022030 | 2026-07-29 | Lakeside Internal Medicine Associates | $424.00 | Denied |
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.