CLM-2026-005197
Harbor Rehabilitation Center, Physical Therapy. Service 2026-04-16 at office (POS 11). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Denise Watkins
- Member ID
- UHC-96328-99
- Date of birth
- 1947-11-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417696
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3519
- Coverage period
- 2024-04-01 to present
- Deductible
- $385.40 of $500.0077%
- Out-of-pocket maximum
- $93.22 of $2,000.005%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 8314850883
- 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 | — | 2 | 1 | $178.00 | $110.36 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $167.00 | $103.54 | — | — | DeniedLIM |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $72.00 | $44.64 | — | — | DeniedLIM |
| Totals | $417.00 | $258.54 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-213443
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001966; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-04-16: CHOICE-PLUS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 34 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 Harbor Rehabilitation Center (1139592160). | |
| 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: Harbor Rehabilitation Center2026-04-16 12:18
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-20 04:10
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-001966; payment withheld until the identity is confirmed. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
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
Annual visit limit exhausted.