Claims workbench/CLM-2026-033542
Professional claim · CMS-1500 · Paper

CLM-2026-033542

Harbor Physical Therapy, Physical Therapy. Service 2026-02-27 at office (POS 11). Received 2026-04-17.

Denied
Billed
$186.00
1 line
Allowed
$115.32
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Melissa Valdez
Member ID
UHC-81960-04
Date of birth
1954-02-10
Identity
Verified5 records, confidence 0.99
Claim record
CLMCLM-407562
Relationship
Child, Dallas, TX

Coverage and accumulators

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-9413
Coverage period
2022-02-01 to present
Deductible
$37.74 of $500.008%
Out-of-pocket maximum
$306.81 of $1,500.0020%
Copays
office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits
4 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
9493518267
Network
In network
Rendering NPI
1686243134
Location
Miami, FL · TIN 59-6364489
Authorisation / referral
none / REF927387

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—21$186.00$115.32——DeniedCO18
Totals$186.00$115.32——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
Patient account
PA-970858
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-006366 (verified, link confidence 0.99).
EligibilityPassActive on 2026-02-27: NAVIGATE-HMO (HMO), effective 2022-02-01.
Timely filingPassReceived 49 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-033541: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Physical Therapy (9493518267).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 4 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: Harbor Physical Therapy2026-02-27 16:36

    Follow-up for pain in right knee. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-04-17 00:38

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

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
    Duplicate check: Exact duplicate of CLM-2026-033541: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0332662026-05-08Mesa Reference Lab$67.00Approved
CLM-2026-0335412026-02-27Harbor Physical Therapy$186.00Approved
CLM-2026-0130062025-12-30Harbor Physical Therapy$244.00Approved

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity