CLM-2026-004476
Evergreen Rehabilitation Center, Physical Therapy. Service 2026-06-14 at office (POS 11). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Barbara Oliver
- Member ID
- UHC-71536-77
- Date of birth
- 1976-07-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-414363
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0891
- Coverage period
- 2025-01-01 to 2026-06-09
- Deductible
- $618.00 of $1,000.0062%
- Out-of-pocket maximum
- $1,163.37 of $4,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 3122667975
- Location
- Phoenix, AZ · TIN 14-6171767
- 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 | — | 2 | 1 | $142.00 | $88.04 | — | — | DeniedCO27 |
| Totals | $142.00 | $88.04 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-668545
- 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-007321 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-14 is after coverage terminated on 2026-06-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 Evergreen Rehabilitation Center (8258289502). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 of 20 for the plan year. Benefit limit reached |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Rehabilitation Center2026-06-14 11:20
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-29 06:07
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 2026-06-14 is after coverage terminated on 2026-06-09. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016462 | 2026-03-03 | Lakeside Imaging Center | $1,880.00 | Needs review |
| CLM-2026-006523 | 2025-12-25 | Lakeside Dermatology Clinic | $999.00 | 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
Service after coverage termination.