Claims workbench/CLM-2026-033992
Professional claim · CMS-1500 · EDI 837P

CLM-2026-033992

Pinecrest Physical Therapy, Physical Therapy. Service 2026-09-11 at office (POS 11). Received 2026-09-22.

PendedIdentity on hold: CASE-001444
Billed
$150.00
1 line
Allowed
$93.00
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Dot Diaz
Member ID
UHC-81135-23
Date of birth
1979-02-20
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-417311
Relationship
Spouse

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-1795
Coverage period
2021-05-01 to present
Deductible
$1,837.18 of $2,500.0073%
Out-of-pocket maximum
$3,654.36 of $7,500.0049%
Copays
office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
8748441127
Network
In network
Rendering NPI
5705892615
Location
Miami, FL · TIN 41-8840384
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—21$150.00$93.00——PendedIDQ
Totals$150.00$93.00——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. Z47.1 Aftercare following joint replacement surgery
Claim header
Patient account
PA-826056
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-001444; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-09-11: SELECT-EPO (EPO), effective 2021-05-01.
Timely filingPassReceived 11 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Physical Therapy (8748441127).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsNotePhysical therapy visits used 18 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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Physical Therapy2026-09-11 11:33

    Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-001444; payment withheld until the identity is confirmed. Benefit limits: Physical therapy visits used 18 of 20.

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

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity