Claims workbench/CLM-2026-034621

Professional claim · CMS-1500 · Provider portal

CLM-2026-034621

Valley Rehabilitation Center, Physical Therapy. Service 2026-06-02 at office (POS 11). Received 2026-06-17.

DeniedIdentity on hold: CASE-003526

Billed

$302.00

2 lines

Allowed

$187.24

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

LIM

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Santiago Silva
Member ID: none on golden record
Date of birth: 1955-12-21
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-424516
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: OPTIONS-PPO PPO group GRP-1877
Coverage period: 2024-09-01 to present
Deductible: $15.66 of $2,500.001%
Out-of-pocket maximum: $4,569.78 of $10,000.0046%
Copays: office $30.00, specialist $75.00, emergency $150.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Valley Rehabilitation Center
Physical Therapy · taxonomy 225100000X
NPI: 6713462326
Network: In network
Rendering NPI: 9949883315
Location: Tempe, AZ · TIN 20-6528291
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	—	2	1	$118.00	$73.16	—	—	DeniedLIM
2	97161	PT evaluation, low complexity	—	1	1	$184.00	$114.08	—	—	DeniedLIM
Totals						$302.00	$187.24	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. M75.100 Unspecified rotator cuff tear, unspecified shoulder

Claim header

Patient account: PA-188393
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003526; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-02: OPTIONS-PPO (PPO), effective 2024-09-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 15 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 Valley Rehabilitation Center (6713462326).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Fail	LIM	Physical therapy visits used 20 of 20 for the plan year. Benefit limit reached
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Rehabilitation Center2026-06-02 14:53
Patient seen for low back pain, unspecified.
SystemSystem: Claims system2026-06-17 00:48
Member has used the annual physical-therapy visit benefit for the plan year.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-17 13:26
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 engineDenied2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003526; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-02: OPTIONS-PPO (PPO), effective 2024-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. Benefit limits: Physical therapy visits used 20 of 20 for the plan year.

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

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