CLM-2026-015690
Heritage Rehabilitation Center, Physical Therapy. Service 2026-07-12 at office (POS 11). Received 2026-07-30.
Member
Resolved through the identity graph
- Member
- Melissa Allen
- Member ID
- UHC-41301-70
- Date of birth
- 1954-02-25
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-432576
- Relationship
- Child, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0120
- Coverage period
- 2025-07-01 to present
- Deductible
- $354.87 of $1,500.0024%
- Out-of-pocket maximum
- $760.44 of $4,500.0017%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 2441270461
- Location
- Nashville, TN · TIN 93-4440762
- 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 | $192.00 | $119.04 | — | — | DeniedLIM |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 2 | $41.00 | $25.42 | — | — | DeniedLIM |
| Totals | $233.00 | $144.46 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-758819
- 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-016818 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-12: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 18 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 Heritage Rehabilitation Center (6638399413). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 21 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: Heritage Rehabilitation Center2026-07-12 14:29
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-30 00:51
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-30 15:51
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028615 | 2026-02-14 | Mesa Physical Therapy | $4,962.00 | Needs review |
| CLM-2026-031405 | 2026-01-21 | Riverside Primary Care Associates | $557.00 | 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
Annual visit limit exhausted.