CLM-2026-012660
Valley Rehabilitation Center, Physical Therapy. Service 2026-03-27 at office (POS 11). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Russell Mitchell
- Member ID
- UHC-20750-76
- Date of birth
- 1999-04-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-426259
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7136
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,152.27 of $1,500.0077%
- Out-of-pocket maximum
- $773.35 of $3,000.0026%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 6237370278
- Location
- Tempe, AZ · TIN 20-6528291
- 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 | $288.00 | $178.56 | — | — | DeniedCO18 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $59.00 | $36.58 | — | — | DeniedCO18 |
| Totals | $347.00 | $215.14 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-245413
- 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-019860 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: OPTIONS-PPO (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 57 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012659: 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 Valley Rehabilitation Center (6713462326). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 1 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: Valley Rehabilitation Center2026-03-27 16:38
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-05-23 03:23
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-012659: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012659 | 2026-03-27 | Valley Rehabilitation Center | $347.00 | Approved |
| CLM-2026-026565 | 2026-02-12 | Sunrise Internal Medicine Associates | $236.00 | Needs review |
| CLM-2026-026564 | 2026-02-12 | Canyon Internal Medicine Associates | $236.00 | 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.