CLM-2026-017105
Harbor Rehabilitation Center, Physical Therapy. Service 2026-05-17 at office (POS 11). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Christian Gutierrez
- Member ID
- UHC-21146-73
- Date of birth
- 2005-07-02
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-410735
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7603
- Coverage period
- 2023-07-01 to present
- Deductible
- $447.85 of $1,000.0045%
- Out-of-pocket maximum
- $354.70 of $2,000.0018%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 9489696416
- Location
- Mesa, AZ · TIN 48-8489623
- 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 | $276.00 | $171.12 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1 | $73.00 | $45.26 | — | — | DeniedLIM |
| Totals | $349.00 | $216.38 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-309257
- 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-032257 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-17: OPTIONS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 8 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 Harbor Rehabilitation Center (1139592160). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 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: Harbor Rehabilitation Center2026-05-17 14:38
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-25 05:21
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-25 09:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
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.