CLM-2026-017237
Harbor Physical Therapy, Physical Therapy. Service 2025-12-10 at office (POS 11). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Gerald Collins
- Member ID
- UHC-51890-28
- Date of birth
- 2008-05-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409917
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1749
- Coverage period
- 2021-10-01 to present
- Deductible
- $1,893.73 of $2,500.0076%
- Out-of-pocket maximum
- $3,136.02 of $7,500.0042%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 8350799135
- Location
- Miami, FL · TIN 59-6364489
- Authorisation / referral
- none / REF816370
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 | $174.00 | $107.88 | — | — | DeniedCO18 |
| Totals | $174.00 | $107.88 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-459341
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002610 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: CORE-HMO (HMO), effective 2021-10-01. | |
| Timely filing | Pass | Received 58 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-017236: 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 Harbor Physical Therapy (9493518267). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 19 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: Harbor Physical Therapy2025-12-10 09:45
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-06 00:53
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-017236: same member, date of service, procedures and billing provider. Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001603 | 2026-04-05 | Evergreen Primary Care Associates | $37.00 | Approved |
| CLM-2026-017236 | 2025-12-10 | Harbor Physical Therapy | $174.00 | 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.