CLM-2026-017579
Harbor Physical Therapy, Physical Therapy. Service 2026-08-15 at office (POS 11). Received 2026-09-10.
Member
Resolved through the identity graph
- Member
- Mary Miller
- Member ID
- UHC-94480-70
- Date of birth
- 1975-10-10
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-415805
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8374
- Coverage period
- 2023-12-01 to present
- Deductible
- $2,077.50 of $2,500.0083%
- Out-of-pocket maximum
- $695.50 of $10,000.007%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 6545056296
- Location
- Miami, FL · TIN 59-6364489
- Authorisation / referral
- none / REF876429
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 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $75.00 | $46.50 | — | — | DeniedLIM |
| Totals | $339.00 | $210.18 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-998591
- 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-015305 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-15: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 26 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 Physical Therapy (9493518267). | |
| 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: Harbor Physical Therapy2026-08-15 10:09
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-09-10 01:27
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-10 14:08
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 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025827 | 2026-02-28 | Northgate Medical Group | $474.00 | 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.