Claims workbench/CLM-2026-032450

Professional claim · CMS-1500 · EDI 837P

CLM-2026-032450

Lakeside Physical Therapy, Physical Therapy. Service 2025-12-19 at office (POS 11). Received 2026-01-04.

Denied

Billed

$179.00

2 lines

Allowed

$110.98

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: Natalie Ramos
Member ID: UHC-54434-24
Date of birth: 1958-04-23
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-419030
Relationship: Self, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-B MA group GRP-4248
Coverage period: 2022-03-01 to present
Deductible: $157.42 of $500.0031%
Out-of-pocket maximum: $455.06 of $2,000.0023%
Copays: office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 8769647701
Network: In network
Rendering NPI: 9919201225
Location: Austin, TX · TIN 82-6971924
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	59	2	1	$114.00	$70.68	—	—	DeniedLIM
2	97140	Manual therapy, 15 minutes	59	1	1	$65.00	$40.30	—	—	DeniedLIM
Totals						$179.00	$110.98	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-678442
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-001151 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-19: MEDICARE-ADV-B (MA), effective 2022-03-01.
Timely filing	Pass		Received 16 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 Lakeside Physical Therapy (8769647701).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Fail	LIM	Physical therapy visits used 22 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: Lakeside Physical Therapy2025-12-19 12:18
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-01-04 03:47
Member has used the annual physical-therapy visit benefit for the plan year.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-04 11:50
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
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-033673	2026-06-13	Unity Primary Care Associates	$150.00	Approved
CLM-2026-024019	2026-06-14	Mesa Physical Therapy	$399.00	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

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

DeniedLIMscenario: Benefit limit

Annual visit limit exhausted.

Review queue Member identity