CLM-2026-002486
Desert Rehabilitation Center, Physical Therapy. Service 2026-08-24 at office (POS 11). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Keith Cruz
- Member ID
- none on golden record
- Date of birth
- 1946-01-14
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-432082
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-8444
- Coverage period
- 2023-04-01 to present
- Deductible
- $2,983.62 of $3,500.0085%
- Out-of-pocket maximum
- $3,854.22 of $10,500.0037%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1142322233
- Network
- In network
- Rendering NPI
- 4338336116
- Location
- Mesa, AZ · TIN 33-5650925
- Authorisation / referral
- none / REF565116
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 | $162.00 | $100.44 | $40.00 | $60.44 | Paid |
| Totals | $162.00 | $100.44 | $40.00 | $60.44 | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-846844
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016403 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-08-24: CORE-HMO (HMO), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 30 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 Desert Rehabilitation Center (1142322233). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 19 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: Desert Rehabilitation Center2026-08-24 12:46
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2026-08-24: CORE-HMO (HMO), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002487 | 2026-08-24 | Meadow Physical Therapy | $162.00 | Needs review |
| CLM-2026-019351 | 2026-02-21 | Sunrise Medical Group | $426.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.