CLM-2026-022295
Heritage Rehabilitation Center, Physical Therapy. Service 2026-01-28 at office (POS 11). Received 2026-02-07.
Member
Resolved through the identity graph
- Member
- Karen Simpson
- Member ID
- UHC-89737-33
- Date of birth
- 1987-05-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402475
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1508
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,362.43 of $2,500.0054%
- Out-of-pocket maximum
- $1,029.67 of $7,500.0014%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 2089597852
- Location
- Nashville, TN · TIN 93-4440762
- 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 | — | 4 | 1 | $248.00 | $153.76 | $30.00 | $123.76 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $200.00 | $124.00 | $0.00 | $124.00 | Paid |
| Totals | $448.00 | $277.76 | $30.00 | $247.76 | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-627876
- 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-011041 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-28: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 10 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 Heritage Rehabilitation Center (6638399413). | |
| 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: Heritage Rehabilitation Center2026-01-28 11:04
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008992 | 2026-08-09 | Heritage Community Hospital | $2,086.00 | Approved |
| CLM-2026-022296 | 2026-01-28 | Heritage Rehabilitation Center | $448.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.