CLM-2026-016218
Heritage Rehabilitation Center, Physical Therapy. Service 2026-07-31 at office (POS 11). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Marcus Gardner
- Member ID
- UHC-24243-44
- Date of birth
- 1991-03-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415778
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4183
- Coverage period
- 2023-07-01 to 2026-02-20
- Deductible
- $180.26 of $2,500.007%
- Out-of-pocket maximum
- $910.19 of $5,000.0018%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 4699010730
- Location
- Nashville, TN · TIN 93-4440762
- Authorisation / referral
- none / REF758700
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 | $264.00 | $163.68 | — | — | DeniedCO27 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 2 | $60.00 | $37.20 | — | — | DeniedCO27 |
| Totals | $324.00 | $200.88 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-595199
- 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 | Pass | Attached to MBR-042569 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-31 is after coverage terminated on 2026-02-20. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 | Note | Physical therapy visits used 18 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: Heritage Rehabilitation Center2026-07-31 16:02
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-13 05:14
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-31 is after coverage terminated on 2026-02-20. Benefit limits: Physical therapy visits used 18 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020342 | 2026-09-16 | Valley Imaging Center | $2,574.00 | Denied |
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
Service after coverage termination.