CLM-2026-001161
Harbor Physical Therapy, Physical Therapy. Service 2026-04-13 at office (POS 11). Received 2026-04-24.
Member
Resolved through the identity graph
- Member
- Arjun Miller
- Member ID
- UHC-81052-83
- Date of birth
- 1987-05-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431709
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9901
- Coverage period
- 2024-06-01 to present
- Deductible
- $942.23 of $1,500.0063%
- Out-of-pocket maximum
- $554.92 of $3,000.0018%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 2302212735
- 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 | — | 1 | 1 | $78.00 | $48.36 | — | — | Review |
| Totals | $78.00 | $48.36 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-954392
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026146 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-13: SELECT-EPO (EPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-001160; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 12 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Physical Therapy2026-04-13 16:21
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-04-24 05:44
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-001160.pdf1 page
Provider cover letter requesting replacement of CLM-2026-001160.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-001160; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001160 | 2026-04-13 | Harbor Physical Therapy | $156.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.