CLM-2026-021873
Evergreen Rehabilitation Center, Physical Therapy. Service 2026-02-10 at office (POS 11). Received 2026-03-26.
Member
Resolved through the identity graph
- Member
- Terry Watson
- Member ID
- UHC-98156-98
- Date of birth
- 1949-06-28
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-404837
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8974
- Coverage period
- 2022-09-01 to present
- Deductible
- $238.11 of $1,500.0016%
- Out-of-pocket maximum
- $430.83 of $3,000.0014%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 6713756396
- Location
- Phoenix, AZ · TIN 14-6171767
- 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 | — | 2 | 1 | $160.00 | $99.20 | — | — | DeniedLIM |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $37.00 | $22.94 | — | — | DeniedLIM |
| Totals | $197.00 | $122.14 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-748235
- 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-022161 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-10: SELECT-EPO (EPO), effective 2022-09-01. | |
| 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 Evergreen Rehabilitation Center (8258289502). | |
| 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: Evergreen Rehabilitation Center2026-02-10 09:22
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-26 04:58
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-26 11:14
Member services inquiry logged on this claim; member asked about the status of payment.
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
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.