CLM-2026-002171
Heritage Rehabilitation Center, Physical Therapy. Service 2026-04-20 at outpatient hospital (POS 22). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Anthony Davis
- Member ID
- UHC-46770-67
- Date of birth
- 1950-09-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413890
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8219
- Coverage period
- 2021-04-01 to present
- Deductible
- $1,030.29 of $1,500.0069%
- Out-of-pocket maximum
- $1,441.35 of $4,500.0032%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 4971506595
- Location
- Nashville, TN · TIN 93-4440762
- Authorisation / referral
- PA2026228913 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 3 | 1 | $8,451.00 | $4,648.05 | — | — | Review |
| Totals | $8,451.00 | $4,648.05 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-420023
- 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-011565 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-20: UNKNOWN (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026228913 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Rehabilitation Center (6638399413). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Rehabilitation Center2026-04-20 09:29
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-23 01:10
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-23 16:31
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026228913_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-20 to 2026-07-19.
- Itemized billitemized_PA-420023.pdf9 pages
Itemised statement totalling $8451.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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
Annual visit limit exhausted.