Professional claim · CMS-1500 · EDI 837P
CLM-2026-000643
Harbor Physical Therapy, Physical Therapy. Service 2026-08-16 at office (POS 11). Received 2026-08-19.
Denied
Billed
$303.00
2 lines
Allowed
$187.86
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jacqueline Willis
- Member ID
- UHC-69078-97
- Date of birth
- 2003-09-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401812
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0166
- Coverage period
- 2024-04-01 to 2026-02-12
- Deductible
- $561.22 of $1,000.0056%
- Out-of-pocket maximum
- $639.59 of $2,000.0032%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 1197011954
- Location
- Miami, FL · TIN 59-6364489
- 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 | $114.00 | $70.68 | — | — | DeniedCO27 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $189.00 | $117.18 | — | — | DeniedCO27 |
| Totals | $303.00 | $187.86 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-449726
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-041961 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-16 is after coverage terminated on 2026-02-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 Harbor Physical Therapy (9493518267). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 6 of 20. | |
| 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: Harbor Physical Therapy2026-08-16 18:21
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
- SystemSystem: Claims system2026-08-19 06:51
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-16 is after coverage terminated on 2026-02-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015188 | 2026-09-29 | Sunrise Imaging Center | $2,395.00 | Denied |
| CLM-2026-014664 | 2026-09-08 | Pinecrest Bone and Joint Center | $222.00 | 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.