CLM-2026-011508
Desert Rehabilitation Center, Physical Therapy. Service 2026-07-25 at office (POS 11). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Jack Gibson
- Member ID
- none on golden record
- Date of birth
- 1939-09-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-403526
- Relationship
- Self
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Desert Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1142322233
- Network
- In network
- Rendering NPI
- 7912192797
- Location
- Mesa, AZ · TIN 33-5650925
- 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 | $189.00 | $117.18 | — | — | PendedIDQ |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $76.00 | $47.12 | — | — | PendedIDQ |
| Totals | $265.00 | $164.30 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-388325
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002496; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 42 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 Desert Rehabilitation Center (1142322233). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for aftercare following joint replacement surgery. Note dictated; signature p”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Desert Rehabilitation Center2026-07-25 09:28
Patient seen for aftercare following joint replacement surgery. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-05 06:22
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002496; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Patient seen for aftercare following joint replacement surgery. Note dictated; signature p”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.