CLM-2026-004448
Harbor Rehabilitation Center, Physical Therapy. Service 2025-12-24 at office (POS 11). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Mark Washington
- Member ID
- UHC-53180-18
- Date of birth
- 2006-12-27
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-421651
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7600
- Coverage period
- 2024-03-01 to present
- Deductible
- $544.89 of $1,500.0036%
- Out-of-pocket maximum
- $2,451.55 of $6,000.0041%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 2968249310
- Location
- Mesa, AZ · TIN 48-8489623
- 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 | $201.00 | $124.62 | — | — | DeniedCO18 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $74.00 | $45.88 | — | — | DeniedCO18 |
| Totals | $275.00 | $170.50 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-135527
- 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-004115 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-24: SELECT-EPO (EPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 50 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004447: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Rehabilitation Center (1139592160). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 4 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 Rehabilitation Center2025-12-24 10:21
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
- SystemSystem: Claims system2026-02-12 01:44
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-004447: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008538 | 2026-09-22 | Heritage Rehabilitation Center | $242.00 | Approved |
| CLM-2026-031864 | 2026-03-01 | Heritage Behavioral Health | $180.00 | Approved |
| CLM-2026-004447 | 2025-12-24 | Harbor Rehabilitation Center | $275.00 | Approved |
| CLM-2026-018099 | 2025-12-08 | Lakeside Physical Therapy | $207.00 | Approved |
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
Exact duplicate of an earlier submission.