CLM-2026-023299
Desert Rehabilitation Center, Physical Therapy. Service 2026-08-11 at office (POS 11). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Charlotte Rogers
- Member ID
- UHC-33731-33
- Date of birth
- 1996-03-20
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-426621
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8405
- Coverage period
- 2022-12-01 to present
- Deductible
- $355.10 of $500.0071%
- Out-of-pocket maximum
- $48.26 of $2,000.002%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1142322233
- Network
- In network
- Rendering NPI
- 6750563218
- Location
- Mesa, AZ · TIN 33-5650925
- Authorisation / referral
- none / REF567626
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 | $201.00 | $124.62 | — | — | DeniedLIM |
| Totals | $201.00 | $124.62 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-673885
- 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-000459 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-08-11: NAVIGATE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 25 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 Desert Rehabilitation Center (1142322233). | |
| 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: Desert Rehabilitation Center2026-08-11 18:12
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-05 03:27
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
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.