CLM-2026-011719
Harbor Rehabilitation Center, Physical Therapy. Service 2026-03-16 at outpatient hospital (POS 22). Received 2026-03-19.
Member
Resolved through the identity graph
- Member
- Catherine Waalsh
- Member ID
- UHC-66390-90
- Date of birth
- 1942-03-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400026
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7583
- Coverage period
- 2023-12-01 to present
- Deductible
- $2,187.33 of $2,500.0087%
- Out-of-pocket maximum
- $1,799.64 of $10,000.0018%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 5301440876
- Network
- In network
- Rendering NPI
- 5069156482
- Location
- Denver, CO · TIN 55-4519384
- Authorisation / referral
- PA2026383371 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 4 | 1 | $9,836.00 | $5,409.80 | — | — | Review |
| Totals | $9,836.00 | $5,409.80 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-119113
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020700 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-16: OPTIONS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026383371 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Rehabilitation Center (5301440876). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| 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 Center2026-03-16 15:43
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-03-19 03:22
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026383371_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-16 to 2026-06-14.
- Itemized billitemized_PA-119113.pdf9 pages
Itemised statement totalling $9836.00 across 1 line.
- Medical recordrecords_PA-119113.pdf12 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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
Routine diagnosis does not support advanced imaging.