CLM-2026-023419
Harbor Physical Therapy, Physical Therapy. Service 2026-09-03 at office (POS 11). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Austin Dominguez
- Member ID
- UHC-89799-58
- Date of birth
- 1954-04-10
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409969
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7488
- Coverage period
- 2022-08-01 to present
- Deductible
- $125.30 of $1,000.0013%
- Out-of-pocket maximum
- $1,419.64 of $4,000.0035%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9493518267
- Network
- In network
- Rendering NPI
- 1536107372
- Location
- Miami, FL · TIN 59-6364489
- 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 | $164.00 | $101.68 | $30.00 | $71.68 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1 | $83.00 | $51.46 | $0.00 | $51.46 | Paid |
| Totals | $247.00 | $153.14 | $30.00 | $123.14 | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-578315
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024964 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-03: SELECT-EPO (EPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 2 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 | Pass | Physical therapy visits used 6 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: Harbor Physical Therapy2026-09-03 15:42
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-09-05 03:32
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-578315.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023198 | 2026-05-23 | Lakeside Imaging Center | $336.00 | Approved |
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
Authorisation must be confirmed with UM before payment.