CLM-2026-004909
Harbor Rehabilitation Center, Physical Therapy. Service 2026-06-02 at office (POS 11). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Steven Watkins
- Member ID
- UHC-18796-43
- Date of birth
- 1956-06-02
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-422534
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9669
- Coverage period
- 2021-12-01 to 2026-08-27
- Deductible
- $966.60 of $2,500.0039%
- Out-of-pocket maximum
- $2,110.55 of $7,500.0028%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 5301440876
- Network
- In network
- Rendering NPI
- 9570093556
- Location
- Denver, CO · TIN 55-4519384
- 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 | — | 4 | 1 | $376.00 | $233.12 | — | — | DeniedCO18 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $41.00 | $25.42 | — | — | DeniedCO18 |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO18 |
| Totals | $480.00 | $297.60 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-786839
- 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-008638 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-02: SELECT-EPO (EPO), effective 2021-12-01, terms 2026-08-27. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004908: 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 (5301440876). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 3 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 Center2026-06-02 14:27
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-29 01:03
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-2026-004908: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004908 | 2026-06-02 | Harbor Rehabilitation Center | $480.00 | Approved |
| CLM-2026-010619 | 2026-03-29 | Lakeside Physical Therapy | $344.00 | 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.