CLM-2026-017527
Harbor Rehabilitation Center, Physical Therapy. Service 2026-02-14 at office (POS 11). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Michelle Bowman
- Member ID
- UHC-64949-34
- Date of birth
- 1971-10-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-430941
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4449
- Coverage period
- 2023-04-01 to present
- Deductible
- $340.99 of $1,000.0034%
- Out-of-pocket maximum
- $583.56 of $2,000.0029%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 2166810509
- 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 | $219.00 | $135.78 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $95.00 | $58.90 | — | — | DeniedLIM |
| Totals | $314.00 | $194.68 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-457718
- 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-013784 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-14: SELECT-EPO (EPO), effective 2023-04-01. | |
| Timely filing | Pass | Received 17 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 22 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 Center2026-02-14 15:43
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-03 06:25
Member has used the annual physical-therapy visit benefit for the plan year.
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 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005897 | 2026-06-29 | Mesa Family Practice | $230.00 | Approved |
| CLM-2026-020538 | 2026-03-19 | Northgate Reference Lab | $38.00 | Approved |
| CLM-2026-005025 | 2026-01-07 | Valley Primary Care Associates | $546.00 | 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.