CLM-2026-022747
Evergreen Rehabilitation Center, Physical Therapy. Service 2026-04-23 at office (POS 11). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Paul Warren
- Member ID
- UHC-23202-90
- Date of birth
- 1988-02-11
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-408927
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9050
- Coverage period
- 2022-04-01 to present
- Deductible
- $723.76 of $1,500.0048%
- Out-of-pocket maximum
- $46.16 of $3,000.002%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 8223831602
- 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 | — | 4 | 1 | $376.00 | $233.12 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | 25 | 1 | 1,2 | $167.00 | $103.54 | — | — | DeniedLIM |
| Totals | $543.00 | $336.66 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-945949
- 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-027322 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-23: MEDICARE-ADV-B (MA), effective 2022-04-01. | |
| 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 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 20 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 Center2026-04-23 11:12
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-05-03 03:10
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 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000440 | 2026-04-06 | Meadow Physical Therapy | $236.00 | Denied |
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.