CLM-2026-002542
Valley Rehabilitation Center, Physical Therapy. Service 2026-02-16 at office (POS 11). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Laura Ellis
- Member ID
- UHC-84006-39
- Date of birth
- 1991-10-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421711
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3756
- Coverage period
- 2024-07-01 to 2026-02-01
- Deductible
- $129.60 of $3,500.004%
- Out-of-pocket maximum
- $3,371.76 of $14,000.0024%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 6793107999
- 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 | — | 3 | 1 | $276.00 | $171.12 | — | — | DeniedCO27 |
| Totals | $276.00 | $171.12 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-892796
- 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-015707 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-16 is after coverage terminated on 2026-02-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 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 | Pass | Physical therapy visits used 2 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: Valley Rehabilitation Center2026-02-16 09:38
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-25 00:48
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-02-16 is after coverage terminated on 2026-02-01.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.